Student payment form
- 1. 2010-2011 ISEP STUDENT PAYMENT FORM Please mail or fax your completed payment form as detailed below. For your security, do NOT return this form via email. Keep a copy for your own records. Submit form to: International Student Exchange Programs 1616 P Street, NW, Suite 150, Washington, DC 20036 USA Tel: (202) 667-8027 Fax: (202) 667-7801 Student Information Last Name: ___________________________ First Name: ___________________________ Country of Residency: __________________ Date of Birth: ____/____/_____ Sex: ______ Host Institution: _______________________ Home Institution: ______________________ Email address: __________________________________ Type of Payment (please check all that apply) • ___ISEP Reciprocal Application Fee $355 • ___ISEP Direct Application Fee $60 • ___Outstanding ISEP Reciprocal Application Fee $10 • ___Extension Fee $100 • ___Health Insurance Premium (per month) $56 X # of months • ___ISEP Direct Deposit $500 • ___Other: (please specify type and amount of charge) _______________________________ $_____ _________________________________________________________ ________________ Signature of Participant Date Method of Payment __ Check/Bank draft or international money order in the amount of US$_______ payable to “ISEP” is enclosed. Any bank fees related to this transaction must be paid by you. If your bank forwards payment to ISEP, please attach proof of payment with the completed enrollment form. Euro-Checks or personal checks drawn on non-US funds are NOT accepted. Deposit items returned for insufficient funds will be charged $30. __ Credit card Select one: o VISA o MasterCard o Carte Blanche o Diner’s Card TOTAL amount to be charged: US$____________ Card Number (please print clearly): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration date: _____/______ Month / year Billing Zip Code: Security Code (on back of card): _____________________________________ ______________________________ _______ Name as it appears on the credit card Signature of Cardholder Date Updated 10/22/2009