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MASTERCARD AND VISA CHARGE
AUTHORIZATION FORM
Check One: Mastercard Or Visa
MLC Student's Name: ________________________________________________________________________
| (Family Name) |
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(First Name) |
Date Student Plans to Attend the MLC:_______________________
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
$825.00 for the rental fee of a shared bedroom at University Towers for a 6-week term
OR
$550.00 for the rental fee of a shared bedroom at University Towers for a 3-week term
OR
$1325.00 for the rental fee of a single bedroom at University Towers for a 6-week term
OR
$795.00 for the rental fee of a single bedroom at University Towers for a 3-week term
DHL Express Mail Courier charge of $_________________________
*DHL prices change very frequently. Please contact the MLC for 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@att.net
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