SIPlive: City Academy - Misc Fees (L.?)

Student's Name	First and Middle Name		Last Name
Student's Name

Amount:

Item Subtotal:

$0.00

Please describe what the payment is for				[1]
Please describe what the payment is for				[2]
Please describe what the payment is for				[3]
Please describe what the payment is for				[4]
Please describe what the payment is for				[5]
Please describe what the payment is for				[6]
Please describe what the payment is for				[7]
Please describe what the payment is for				[8]
Please describe what the payment is for				[9]
Please describe what the payment is for				[10]

Would you like to make a donation?:

Item Subtotal:

$0.00

Total:

$0.00

Personal Information

First Name:		Last Name:
Phone:		Email:

Payment Information

Method of Payment:

Processing Fees:

Credit cards: 3% plus $0.50
(+1.5% processing fee for foreign cards)
eChecks: $0.50

	Update name from Personal Information
Name of Individual on Checking Account: Name of Individual on Savings Account: Name of Business on Checking Account:
Bank Routing Number:
Bank Account Number:

Cardholder Information (exactly as it appears on your statement)
	Update from Personal Information
Cardholder's Name:

Billing ZIP/Postal Code:

Unnamed Item:


SIP Program & Data © 2006-2019 Instant Payments All rights reserved. ~ Terms & Conditions ~ Privacy Policy ~ Contact Us ~ SIP Version 2.78.8688; (API: 2.14)