For Official Use Only:
CSID____________________________
PLEASE DO NOT SEND CASH. If not paying by credit card, attach an international or US money order.
Make money order payable to San Diego Mesa College.
Student’s Name (
PLEASE PRINT): _________________________________________________________________________
ACCEPTING ONLY VISA AND MASTERCARD.
MASTERCARD
CARD HOLDER’S NAME (AS IT APPEARS ON THE CARD): _________________________________________
16 DIGIT CREDIT CARD NUMBER: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
SECURITY CODE (3 OR 4 DIGIT CODE ON THE BACK OR CARD): ___ - ___ - ___ - ___
EXPIRATION DATE: _____________ _____________
MONTH YEAR
BILLING ADDRESS OF THE CREDIT CARD HOLDER:
________________ _____________________________________________ ______________________
NUMBER STREET APARTMENT NUMBER
______________________ _______________________ ________________ ____________________
CITY PROVINCE/ TERRITORY/ STATE POSTAL/ ZIP CODE COUNTRY
I authorize the San Diego Mesa College Accounting Office to charge $100.00 to my credit card as payment for the
non-refundable International Student Program application processing fee.
Cardholder’s Name (PLEASE PRINT): ______________________________________________________________________
Cardholder’s Signature: ________________________________________ Date: ______________________________
International Student Program
Application Fee Payment Form
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619)388-2717
