COURSE TITLE______________________________Dept_____Course #_____

Credits____

INSTRUCTOR________________Location_____________

Fall____Spring____Summer____

NAME__________________________________________________ Last First Middle/Maiden

SOCIAL SECURITY NUMBER_________________HOME PHONE_______

WORK PHONE________

PERMANENT ADDRESS__________________________________________

CITY__________________COUNTY__________STATE______ZIP_____

BIRTHDATE______________________

High School Graduation Year__________________

Attended WMC: Yes___No___ Approximate Dates_____________________

Degree:______Name used (if other than above)_____________________

Other college(s) attended:_________________________

Dates____________________

FEES: Registration Fee $__________

Lab Fee (if required) $__________

Textbook Fee (if any) $__________

1) TOTAL FEES:$________

(include $30 deferred payment charge if you are selecting that method of payment.)

DEFERRED PAYMENT: Amount Paid (1/3 of #1)

2) $_____________

Balance Deferred by Student (#1-#2)

3) $_____________

Balance Due (same as #3)

4) $_____________

METHOD OF PAYMENT:

____Check or Money Order

____Deferred payment (Deferred payment must have a down payment of 1/3 of total fee plus the $30 deferrment charge.) I hereby agree to pay 1/2 of the balance due (#4) within 45 days and the remaining 1/2 within 90 days of the date of this form. I understand that if payments are not made on time, I will be assessed an additional $15 for each late installment payment. If I drop this course after 3 weeks, I understand I am still liable for any outstanding deferred installments plus all attorney's fees and other costs and charges necessary for the collection of any amount not paid when due. I have read and agree to the terms of this deferred payment agreement.

___________________________________ _________________

Student's Signature Date

____VISA

____MASTERCARD

____DISCOVER

________________________________ _________________

Card Number Expiration Date

________________________________ _________________

Cardholder's Signature Date