Payment Coupon

Payment Coupon

Credit Card Payment Authorization

You may pay with a credit or debit card by completing that information on this form.

Alternatively, the completed Form can also be scanned and emailed to: payment@intercoast.edu or submitted by fax to (818) 717-7945.

First Name*

Last Name*

Maiden name or other name while attending

Last four digits of Social Security Number*

Cell Phone Number to receive Confirmation*

Email*

Billing Address (Street or PO Box)*

Billing Address City, State, ZIP*

Campus*

Select or enter value

Program*

Select or enter value

Employed in the Field?*

Select or enter value

Employment Status*

Select or enter value

Employer Name

Work Location

Position

Hire Date (month and year)*

Tell us about friends or family that will benefit from the training offered at InterCoast.

Please provide names and phone number of two referrals

Comments

Type your name here to authorize your charge.*

If paying with a debit or credit card, please complete the following. Paying by credit card on our web form is encrypted and secure. However, students may call 818-672-2100 to give card number over the phone.

Indicate Credit Card Type

Select

I authorize InterCoast to charge the above card in the amount of:

Credit Card Number

Name on Card

Expiration Date

VIN Code 3 digits for MC, VISA, Discover

Send me a copy of my responses

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