For Office Use ONLY
Student ID #
Initial, Date, and Qtr
Admission Application/Express Mail Fee Payment
by Credit or Debit Card Form
Please complete this form and
fax to: (408) 864-5638
Admission for Quarter/Year:
Please check one
Fall Year _________
Winter Year _________
Spring Year _________
Purpose and Amount of Payment:
Please Check all that apply
Admission Fee: US$75 (non-refundable)
Express Mail Fee: US$75 (non-refundable)
Note: Admission related documents will not be shipped
internationally until we receive the express mail fee.
Today’s Date: ________________________________________________________________________________________________
Student’s Name (As it appears on your passport):
Family/Sur/Last name Given/First name
Type of Card (MUST CHECK ONE): VISA Mastercard Discover
Credit Card #: _____________________________________________
Expiration Date (month and year): ______________________________
Security Code (3 digit code on back of the credit card): _____________
Name on Card (cardholder): ___________________________________
Card Billing Address: ________________________________________________________________
Number and Street
City, Province or State, Country, Postal Code
Authorized Signature of Cardholder: _______________________________________________________
Express Mail Fee
All admission packets and mailings to addresses outside of the U.S. will be sent by DHL express due to security and tracking. A
shipping and handling fee of US$75 will be charged to the above credit/debit card. Be sure to check the Express Mail Fee button
above. For certain countries on the Embargo List due to higher tariff of that country, US$100 will be charged.
Please tell us the address you want us to mail your Admission Documents to:
Mailing Address:________________________________________________________
Number and Street
_______________________________________________________ ________________________________
City, Province or State, Country, Postal Code International Phone Number REQUIRED
NOTE: If you do not wish De Anza College to send the admission packet to your country, arrange for a friend/relative to pick up the
packet from our office or request De Anza to mail the packet to a U.S. address.
Revised: January 17
De Anza
21250 Stevens Creek Blvd.
Cupertino, CA 95014