Security Code
(3 or 4 digit code on back of card): _______________________________________________________
Expiration Date: _________________________________________________________
Visa MasterCard
16-digit credit card number
Cardholder’s Name: __________________________________________________________
(Please Print)
Cardholder’s Signature: ________________________________________Date:___________
If not paying by credit card, attach an international or US money order.
Student’s Name: _________________________________________________________
Card Holder’s Name: _____________________________________________________
Billing Address of the Credit Card Holder:
(Include street number, apartment number, ZIP code number & Country)
(Please Print)
I authorize the San Diego Mesa College Accounting Office to charge $100.00 to my credit card
as payment for the International Students non-refundable application processing fee.
7250 Mesa College Drive, San Diego, CA 92111-4998
(619) 388-2717 (619) 388-2960 FAX
This form is also available online at:
Please do not send cash.
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