Please Print out this form. Fill in all fields. Then, sign and FAX this form to us.
For students that have a current credit card on file, and does not need updating disregard this form.
ACCOUNTING FAX: (602) 648-5755
STUDENT CHARGE INFORMATION
Student Name |
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Student Daytime Phone
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Student Company / Employer
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Amount to Be Charged
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Course / Service Description
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DEBIT / CREDIT CARD INFORMATION
Card Type |
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Credit Card Number (16 Digits) |
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Expiration Date
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CCV 3 Digit Code
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Card Billing – Cardholder Full Name
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Card Billing – Cardholder Address
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Card Billing – Cardholder Address 2
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Card Billing – Cardholder City
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Card Billing – Cardholder State / Province
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Card Billing – Cardholder Zip Code
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Card Billing – Cardholder Country
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Card Billing – Cardholder Phone
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I have read and agree to the terms and conditions of the Tuition
Deferral Promissory Note and I authorize Dunlap-Stone University to charge my card for tuition 28 days after the start date of each
course in which I register.
I affirm and confirm that the electronic signature shown below is my legal
signature for purposes of this Promissory Note and my Enrollment Agreement.
NOTE: Once we have this form on file,
you only need use you electronic signature as your signature for future courses as long as the card remains valid. If the card information is not valid you must re-submit this form. The electronic signature should match the electronic signature on the online form. This form while takes longer to complete than an online form offers a better level of protection against credit card theft.
| Card Holder Signature |
[___________________________] |
| Electronic Signature |
[___________________________] |
| Date |
[______/______/______] |
ACCOUNTING FAX: (602) 648-5755
NOTE Your deferral can not be processed
until we have your signature on file.