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MASTERCARD AND VISA CHARGE AUTHORIZATION FORM 


Check One: Mastercard Or Visa 

MLC Student's Name: ________________________________________________________________________
  (Family Name) (First Name)
Date Student Plans to Attend the MLC:_______________________
  (Month) (Year)

Cardholder's Name: ________________________________________________________________________
  (Family Name) (First Name)

As the cardholder, I give my permission for the following charges to be made on my credit card: 
$100.00 for the Non-Refundable Application and Advance Tuition Fee 

$200.00 for the Non-Refundable Housing Deposit and Reservation Fee for a shared bedroom at University Towers 
 
 

or

$300.00 for the Non-Refundable Housing Deposit and Reservation Fee for a single bedroom at University Towers

DHL Express Mail Courier charge of $_________________________
            *DHL prices have changed.  Please contact the MLC for new DHL rates.

Other __________________________________________________________________

TOTAL AMOUNT TO BE CHARGED:________________ 

Account Number:#__________________________________ 

Expiration Date: ___________________ Card Security Code (CSC): _ __________
  (Month) (Year)

 

Please Read and Sign 
I understand that the Application and Advance Tuition Fee and the Housing Deposit and Reservation Fee are Non-Refundable. 

Cardholder's Signature____________________________________________ Date:___________________

Michigan Language Center
309 S. State St.
P.O. Box 8231
Ann Arbor, MI 48107, U.S.A.
Tel: (734) 663-9415
Fax: (734) 663-9623
E-Mail: MLC-USA@worldnet.att.net

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