NAME__________________________________________

 

SS #___________________________________________

 

ADDRESS______________________________________

_______________________________________________

 

PHONE

(DAY)_______________(EVENING)_________________

 

EMAIL ADDRESS______________________________________

 

NAME OF COURSE______________________________

 

START DATE___________________________________

 

FORM OF PAYMENT    CASH_______CHECK#_______

CREDIT CARD _____________

 

To pay by Discover, MasterCard or Visa please complete this section.

 

I, _______________________ authorize Lackawanna College to charge $____________ to my Master

card#_____________________________ 

Expiration Date: ____________________                                                     

to charge $___________to my Visa

card#_____________________________

Expiration Date: ____________________                                                 

to charge $ __________ to my Discover

card #_____________________________                                                

Signature________________________________________

Date ____/____/____