Your Name:
 
Address:
 
City:
State/Province:
 
Postal Code/ Zip:
 
Email:
 
Country:
 
Please Enter the Amount You Are Paying in U.S. Dollars:
Please use one of the following payment options(personal check, or credit/debit card)

Payment Using a Personal (or other) Check

We will make your check payable to Institute for Online Studies

Name on Check:
 
Address on Check:
 
Routing Number:
(First set of numbers at the bottom of the check)

Account Number:

(Second set of numbers at the bottom of the check)
Check Number:
Name of Bank:
 
Bank Address
(on check):
 

*** Please remember to VOID this check in your check book! ***

Payment Using a Credit or Debit Card

Card Type:
 
Name on Card:
 
Card Number:
 
CIV #:
(Three numbers on the back of card, or four on front of American Express)
Expiration Date:
 
Billing Name/Address for Cardholder:
(if different than your name and address shown above)

Representative:

I hereby authorize you to charge my account as indicated above.