3100 Main Street, Houston, TX 77002 T 713.718.8521 F 713.718.2112 W hccs.edu/international Rev. 5/5/17
All fields marked with * are required and must be completed.
*1. Personal information
___________________________ ___________________________ _______________________
Family (Last) Name First Name Date of Birth (MM/DD/YY)
*2. Fee type:
___$75 Application Fee
*3. Payment type:
Please select one.
___Check ___Money Order ___Cashier’s Check
Note: HCC does not accept temporary or international checks. Checks or money orders should be
made payable to Houston Community College and have your HCC student ID written in a space on
the slip. Don’t forget to sign and date the document.
4. Attach the check or money order to the form and submit:
For Office use only:
OISS$SA Staff initials _____ Date______
Change-of-Status Fee Payment Form
*HCC ID: ______________________