PMT#
DUE DATE
AMOUNT DUE
1
2
3
4
5
6
7
8
9
10
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$
STUDENT INFORMATION:
Iisaġvik College
PO Box 749, Barrow, AK 99723
Ph. 907-852-3333 Fax 907-852-2652
Student Payment
Plan
Last Name: First Name: M.I.
Billing Address: City: State: Zip:
Home
phon
e
:
Me
ssag
e
phon
e
:
E
-m
ail:
PAYMENT SCHEDULE:
Previous semester(s) account balance:
Se
mester
/ Y
ear:
/
$
Current semester account balance:
Se
mester
/ Y
ear:
/
Tuition Fee
$
Registration Fee
$
Technology fee
$
Course/Material/Lab fees
$
TOTAL CURRENT
CHARGES:
$
TOTAL
CHARGE
S:
$
PAYMENTS MAY BE MADE IN CASH, CHECK, MONEY ORDER, CREDIT/DEBIT CARDS (Visa/MasterCard).
CARD#: Exp Date: CSC/CVV:
Cardholder Name (print): Cardholder Signature:
AGREEMENT:
I have read and understand the information listed above. I also understand that by signing this form, I am financially
responsible for any and all charges incurred. I understand that Iisaġvik College is extending short-term credit to me and I
agree to repay the amount indicated above by the end of the semester. Failure to do so will result in my account being placed
on financial hold. In addition, I understand that grades, transcripts, certificates, CPR cards and NSTC cards will be withheld as
long as my account is in financial hold status. I also understand that I will be (1) denied participation in graduation ceremonies
as long as my account is in financial hold status, and (2) prevented from registration for future classes until my account is paid
in Full.
Students Signature Date
If you have questions, please contact the Business Office:
(907) 852-1834
e-mail: arian.austria@ilisagvik.edu
Approved:
Initial Date
Business Office Verified Acct. Information
Revised March 2019
click to sign
signature
click to edit
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