Registration - Online Payment
Note: This payment form is for
traditional students
only.
Student Information:
Student First Name:
(Required)
Student Last Name:
(Required)
Date of Birth (mm/dd/yyyy):
(Required)
(Invalid Date of Birth)
Living Arrangements:
---
On Campus
Off Campus
(Required)
Payment Information
Cardholder First Name
(Required)
Cardholder Last Name
(Required)
Card Number
(Required)
(Invalid)
Expiration Month
01
02
03
04
05
06
07
08
09
10
11
12
Expiration Year
24
25
26
27
28
29
30
31
32
33
Card Security Code
(Required)
(Invalid)
Amount
(Required)
(Invalid)
We Accept
Email Address (for receipt)
(Required)
(Invalid Email)
