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MASTERCARD AND VISA CHARGE
AUTHORIZATION FORM
Check One: Mastercard Or Visa
MLC Student's Name: ________________________________________________________________________
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(Family Name) |
(First Name) |
Date Student Plans to Attend the MLC:_______________________
Cardholder's Name: ________________________________________________________________________
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(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): _ __________
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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