Fillable Application Fee Paymentby Creditor Debit Card Formfillible (Las Positas College)

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Application Fee Paymentby Creditor Debit Card Formfillible (Las Positas College)

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International Student Program
3000 Campus Drive
Livermore, CA 94551-7650
Tel: 925.424.1540
Fax: 925.424.1877
Web: www.laspositascollege.edu/international
$100 Application Fee Payment by Credit/ Debit Card Form
Please use this form ONLY if you are paying the Application fee by credit / debit card.
If you are paying by check or money order, you do NOT need to complete this form.
Student’s
Name:
Family (Last) Name
First Name
Name:
Exactly as it appears
on the credit card
Address:
The address on
record with the
credit card company
Credit Card Type: Visa MasterCard
Check one
Credit Card Number:
Expiration Date:
/
Credit Card 3-Digit Security code:
This is the 3-digit code found on the back of your card. It is the last 3 digits located in the signature section.
Amount to be charged: $100.00
Signature of Credit Card holder:__________________________________
Date:___________________
Please mail this form along with your application or fax it to:
Las Positas College, International Student Program
Fax: 1-925-424-1877
Note: To protect your security, the ISP Office will shred this document after the payment is received.
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Application Fee Paymentby Creditor Debit Card Formfillible (Las Positas College)

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Completed 22 July 2020

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