Proposed Computerized Enrolment System

Topics: Credit card, Payment, Debit card Pages: 6 (991 words) Published: January 23, 2013
MANUAL COURSE ENROLLMENT FORM

MANUAL COURSE ENROLLMENT FORM

From our Home Page or our literature, please choose the type of course format you would like, select a subject area, choose the course(s) you would wish to enroll, and complete & mail this form to manually enroll for courses.
THE FOLLOWING SECTIONS MUST BE COMPLETED FOR MANUAL ENROLLMENT. PERSONAL INFORMATION & LOG-IN INFORMATION

PERSONAL INFORMATION & LOG-IN INFORMATION

SSN* ______________-__________-______________ BIRTH DATE* ______/_______/__________ (Please see Privacy Policy for additional information.)

NAME* ______________________________________________________________________________________ Title / First Name / Middle Name / Last Name

ADDRESS* ____________________________________________________________________________________ Street / Apt. or Unit # / City / State / Zip

PHONE(s)* ___________________________________________________________________________________ Home Phone # / Cel Phone # / Other Phone #

EMAIL* ___________________________________________________@__________________________________

ALT EMAIL ________________________________________________@__________________________________

PASSWORD* _________________________________________________________________________________ (Please provide your Site Password, or create a Password here in order for us to manually enter you into our site.)

SCHOOL DISTRICT* ______________________________________ (Please email or call us if you are in the LAUSD)

PREVIOUS VANGUARD STUDENT: □ YES □ NO / PLEASE CHECK IF ANY OF THE ABOVE INFO HAS CHANGED □

COURSE INFORMATION – for MANUAL ENROLLMENT

COURSE INFORMATION – for MANUAL ENROLLMENT

CLASS NUMBER:________________ CLASS TITLE:____________________________________________________

PROVIDER: □ FACE-TO-FACE □ PDE □ ASCD □ ANNENBERG □ OTHER ___________

COURSE CREDIT:_________ LOCATION & DATE: ____________________________________________________
(If Applicable)
COST PER UNIT
Regular Enrollment Fee: $ 276.00
Late Enrollment Fee: $ 10.00 (Currently Waived)
(Late Enrollment fee applies if payment clears after the first FACE-TO-FACE class has begun) Manual Enrollment Fee: + $20.00 (Coordinator Code: _______________) TOTAL FEE ENCLOSED: $ 296.00

PLEASE FILL OUT ANOTHER FORM FOR EACH ADDITIONAL COURSE.
MANUAL ENROLLMENT PAYMENT OPTIONS

MANUAL ENROLLMENT PAYMENT OPTIONS

Payment for college credit may be completed through PayPal through our secure transaction credit/debit online processing system. We allow for exceptions to this process by the Learner completing this form and submitting payment via Credit Card, Money Order, E-Check, or Cashier’s Check. Please mail the payment and the completed form to: College Credit Connection, LLC.

2331 Honolulu Ave., Suite H
Montrose, CA 91020

Credit Card Information will be processed through PayPal’s Credit Card system. Please supply the following information if you wish CCC to process your Credit Card as such:

Type of Credit Card: □ Master Card □ Visa □ Discover □ AMEX □ PayPal

Name on Card: _________________________________________________________________________

Number on Card: ____________________-____________-____________________

Expiration Date: ____/______ Security Code : ________ Amount Approved to be Charged: $__________

Signature Authorizing CCC to process: _______________________________________________________

Please supply the following information if you wish CCC to process...
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