CLASS Internet Payment Form

CLASS Internet Payment Form
For CLASS accounts only (existing balances, fees, donations or extension quarters) Please do not use this form to enroll. Instead, you may enroll online at: www.shopchristianliberty.com.
FormID
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Family or Student ID Number *
Billing Name *

First Name Last Name
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
In case we need to contact you about this transaction:
Phone Number
Email *
example@example.com
Is the billing address above the same as the CLASS family mailing address? *

Yes No
Family Name *

First Name Last Name
Family mailing address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please enter the amount you wish to apply to your balance.

Note: To add Extension Quarters pleases use the form at the bottom.
Pay My Bill
Please apply my payment toward: (Check all that apply) *

My Current Balance Time Payment Installment Shipping Fees Chargeable Course Fees Transcript Fees (for requests already in process only)
Would you consider donating to our scholarship fund to help another family?

Not at this time $10.00 $25.00 $50.00
Would you like to purchase Extension Quarters?

Yes No
Please Note: Only three extension quarters are allowed per any one grade level for a student. Extension quarters are added to the basic four quarters included in the basic tuition.
Student ID Number *
Student Name *

First Name Last Name
Extend Which Grade Levels? *

K 1 2 3 4 5 6 7 8 9 10 11 12
Number of Extensions *

$35.00 (One quarter) $70.00 (Two Quarters) $105.00 (Three Quarters)
Extend Another Grade Level?

Yes No
Student ID *
Student Name *

First Name Last Name
Extend Which Grade Levels? *

K 1 2 3 4 5 6 7 8 9 10 11 12
Number of Extensions *

$35.00 (One quarter) $70.00 (Two Quarters) $105.00 (Three Quarters)
Extend Another Grade Level?

Yes No
Student ID *
Student Name *

First Name Last Name
Extend Which Grade Levels? *

K 1 2 3 4 6 7 8 5 9 10 11 12
Number of Extensions *

$35.00 (One quarter) $70.00 (Two Quarters) $105.00 (Three Quarters)
Extend Another Grade Level?

Yes No
Student ID *
Student Name *

First Name Last Name
Extend Which Grade Levels? *

K 1 2 3 4 6 7 8 5 9 10 11 12
Number of Extensions *

$35.00 (One quarter) $70.00 (Two Quarters) $105.00 (Three Quarters)
Comments:
Form Total

Payment

USD Total Payment

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty: