Conversational Spanish Payment Form

Billing Information

Company

Contact Name*

E-mail*

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone

Area CodePhone Number

Fax

Area CodePhone Number

Program Info

2011 Conversational Spanish Courses Only $220.00

**Your credit card will be billed for the total amount, please contact Program Coodinator William Hamilton at (713) 313-7489 with any questions.

Card Information

Card Type*

Name on Card*

Card Number*

Issuing Bank*

Expiration Day*

Expiration Year*

Credit Card Authorization

By entering your full name and checking the authorize box, You acknowledge the charges described herin and undertake to make payment inwill when billed or in extended payment, in accordance with standard policy of the credit card company, which issued the card.

I authorize Texas Southern University to charge my credit card*

Yes

Credit Card Holder Name*

Enter the message as it's shown*