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

Hire Date*

Statement of Certification of Electronic Signature

In accordance with federal law pertaining to the Family Educational Rights & Privacy Act, transcripts will not be released to a third party without the student’s written permission.

By typing my name here I am signing this document electronically, I certify that the information above was provided by me and I certify that my electronic signature used on this document is a legally binding equivalent to my handwritten signature.

Type your full name here to certify your request.*

I am making a tuition/institutional charges payment to InterCoast as noted below.

This payment is coming from the following source:

Please choose source of payment.*

Select or enter value

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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