Balance Payoff Form - Cuba Clinical Travel

Clinical Travel with MedSchoolCoach

Payoff Form
Student Name*

First NameLast Name
Billing Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Pay Balance*

Ultimate Med Immersion Balance After Deposit

If you wish to pay in full at a later date, you have until September 6, 2021. Our team will contact you to collect the remaining balance.

$5,550.00

Single Occupancy Room Supplement

If you wish to stay in a single occupancy room you can do so at an additional cost of $100 per night. Limited rooms will be available, and will be awarded on a first-come, first-served basis.

$1,000.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Clinical Travel with MedSchoolCoach

Billing Information