Fee Payment Form

Payment on Behalf of (Full Name):

When did you complete the IEP Application Form? —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember—Please choose an option—12345678910111213141516171819202122232425262728293031—Please choose an option—201920202021

Applicant's Email:

Name on Card:

Card Number:

Expiration Date: —Please choose an option—01 January02 February03 March04 April05 May06 June07 July08 August09 September10 October11 November12 December—Please choose an option—20172018201920202021202220232024202520262027202820292030

Billing Zip Code (Postal Code):

Visa or Mastercard? VisaMastercard

Fee to Pay: —Please choose an option—$125.00 Application FeeHousing Fee: see notesOther: see notes

Notes/Other Amount:

By clicking "Submit" below, I agree that I am the person whose name appears on the credit card information above, and that I agree to pay thenon-refundable IEP Application Fee (or other charge as specified).

I agree

Note: If the information on this form does not match the information on the IEP Application Form, the Application Fee will not be processed.