Membership Fees Payment Plan

Thank you for your interest in setting up a payment plan for your membership fee! Please fill out the form below and make your first monthly payment. Please feel free to contact the National Office at 614-488-4094, or email Thomas Dickhaut at tdickhaut@mortarboard.org with any questions.

Member Information

Name *

First Name Last Name

College or University *

Phone Number *

Area Code Phone Number

Email *

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Payment Information

Payment plan length *

4 Payments ( $ 20.00 for each month )

Four (4) monthly payments of $20.00.

5 Payments ( $ 16.00 for each month )

Five (5) monthly payments of $16.00.

2 Payments ( $ 40.00 for each month )

Two (2) monthly payments of $40.00.

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Please verify that you are human *

Thank you and congratulations on your selection into Mortar Board!