Mcma Washington Dc Payment Form

DIVISION OF CONTINUING EDUCATION REGISTRATION FORM Washington D.C. Studies Program Department of Radio-Television, Department of Cinema & Photography, and School of Journalism - Summer 2010

Please print, sign, and return with your payment of the program/housing fee: Name: ____________________________________________________ Gender: _____ Male _____ Female (First )

(MI)

(Last)

Present Address: (Good until_____/_____/_____)

Permanent Address:

_________________________________________

___________________________________________

Street Address

Street Address

_________________________________________

_________________________________ _________

Street Address (continued)

Street Address (continued)

_________________________________________ City

State

Phone: (

Zip Code

)_____________________________

E-mail:___________________________________

__________________________________________ City

State

Zip Code

Phone: (

)_____________________________

E-mail:_____________________________________ (If different from present address)

In case of emergency, notify: ______________________________ Relationship:_____________________ Day Phone: ( Cell Phone: (

) _________________________ ) _________________________

Evening Phone: (

) _______________________

Email: ______________________________________

Available housing at American University has two single beds per bedroom; therefore, you must have a roommate. (If you do not list a roommate by April 23rd, a roommate will be randomly assigned.) Roommate: ______________________________________________________________________________ Housing/Program fee: $2,850.00 (may be paid in three installments: March 26, April 9, and April 23) (We accept Visa, Discover, MasterCard, check or cash. If paying by credit card, there will be an additional charge of $65.)

Double Occupancy - $2,850 plus the credit card fee of $65 – check or cash only 










3 Installments 3/26, 4/9, & 4/23 Paying in full Payment by check: Make check payable to: SIUC

Check #: ____________ Amount: $______________

Payment by credit card (If you are paying by credit card, you can pay by phone; call (618) 536-7751.) Credit card #: ______________________________________________ Exp. Date: _____________________ Name on Card: ___________________________________________________________________________ Authorized Signature: _____________________________________________________________________ Mail or bring form to: Washington D.C. Studies, Jackie Welch, Division of Continuing Education, Washington Square Building C, MC 6705, Southern Illinois University, Carbondale, IL 62901 This form must be returned to Continuing Education with your payment of the housing/program fee!