* Student First Name:

* Student Last Name:



Subtotal:
Convenience Fee (2.9%):
      (Convenience fee applies to the following payment methods: Credit Card)
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Total:


Please enter the credit card information requested below:


*Card Holder's First Name:
*Card Holder's Last Name:
*Address:
*City:
*State:
*Postal Code:
*Credit Card Number:
*Credit Card Type:
*CVV2 / CVC2 / CID (located on the back of the card):
*Expiration Date (MMYY):
*Enter Email Address for Receipt:
*Enter Daytime Telephone: