Launch High School

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Student Name	Lastname	,	Firstname	-	ID#
Student Name

Launch High School

Chromebook Insurance (Optional):

$20.00

Select:

Item Subtotal:

$0.00

Chromebook Repair: Screen:

$35.00

Select:

Item Subtotal:

$0.00

Chromebook Repair: Keyboard:

$20.00

Select:

Item Subtotal:

$0.00

Chromebook Repair: Damaged Case:

$20.00

Select:

Item Subtotal:

$0.00

Chromebook Replacement:

$250.00

Select:

Item Subtotal:

$0.00

Chromebook Charger Replacement:

$25.00

Select:

Item Subtotal:

$0.00

Launch Donation:

Item Subtotal:

$0.00

Launch Fundraiser:

Item Subtotal:

$0.00

Launch Other:

Item Subtotal:

$0.00

Please describe your payment

Total:

$0.00

Payer's Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Payment Information:

Processing Fee Rates:
Cards:	3% plus $0.50 ($1.50 min)
eCheck:	$0.49

Method of Payment:	Credit/Debit Card eCheck
Update Name from Above

Name on Account:
Routing Number:
Account Number:
Institution:

Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:

Payment method will be collected on external device

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Please be aware that payments will reflect on your statement as

CBT*Iron County School and CBT*Svc Fee Iron School

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