International Education Programs
4500 Steilacoom Blvd. SW
Lakewood, WA 98499 USA
Tel: 253.589.6089 Fax: 253.589.6056
Student Name: ___________________________________
Student ID#: 975 - __ __ - __ __ __ __
Name of Card Holder:
Billing Address for this card:
Card Type (circle one): Visa MasterCard (*AMEX and Discovery Card are NOT accepted)
Card Number:
Expiration Date: / Security Code:
(The security code is the last 3 digit numbers on the back of your card)
Amount to be charged in US dollars:
Application Fee (M7): $70
Housing Fee (M8): $150 (This fee is NOT the Homestay Placement Fee)
Health Insurance Fee (M9): $365.13
Tuition & Fees: $________________
Other (please specify): $_________________ for __________________
Total: $__________________
______________________________ ____________________
Signature of Card Holder Date
Important Note: An original copy of this form is needed to process charges.
Please print this form and send with your application by mail to:
International Education Programs
Clover Park Technical College
4500 Steilacoom Blvd. SW
Lakewood, WA 98499 U.S.A.
Last updated 06/09/2020 yc