August 2016
Class/Course Charge Card Form
Student Name: _______________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
City/State/Zip: _______________________________________________________________________________________________
*Course, Technology, Insurance, and Other Fees
Course/Class: ____________________ Section #: _________ Reg. Fee: ________ Other Fees: ________ Sub Total: ___________
Course/Class: ____________________ Section #: _________ Reg. Fee: ________ Other Fees: ________ Sub Total: ___________
Course/Class: ____________________ Section #: _________ Reg. Fee: ________ Other Fees: ________ Sub Total: ___________
Books: _________________________ Total: ____________
Method of Payment:
PLEASE CHECK ONE: All Credit orders subject approval:
MasterCard: _____ VISA: _____ Discover: _____
Credit Card Number: _____________________________________________Exp. Date: ____________________ CVV#:____________
Signature: ___________________________________________________________________________________________________
Name, Address, and Phone Number of Cardholder: __________________________________________________________________
Registered by: Mail __________ Walk In ________ Phone __________ Fax ________
Refunds are allowed under the following circumstances
1. A student who officially withdraws, in writing, from an occupational extension class prior to the first class meeting or if a
class is cancelled shall be eligible for a 100% refund.
2. After class begins, 75% shall be refunded at the request of the student if the student officially withdraws, in writing, from
the class prior to or at the 10% point of the scheduled hours of the class. Note: This rule is applicable regardless of the
number of times the class meets or the number of hours the class is scheduled to meet.
3. For contact hour classes, students must withdraw, in writing, within 10 calendar days.
4. Appropriate local refund policies will be established for self-supporting classes.
5. If a student, having paid the required registration fee for a semester, dies during that semester (prior to or on the last day of
examinations of the course the student was attending), all registration fees for that semester will be refunded to the estate
of the deceased.
For Office Use Only
Payment Received by: _________________________________________________________ Date: ________
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