Payment Form Please complete this form and return it by Fax: +1-212-796-8359 Mail: 19 West 21st Street, Suite 702 New York, NY 10010 Or email: firstname.lastname@example.org Student Information Student Name: (Please Print) First Student ID#: Last Program(s): Credit Card Information □ VISA □ Mastercard Credit card number: _______________________________________________ Name of cardholder: _____________________________________________ Total amount: _____________ Expiration date: ______________ 3 digit security code: ______________ Authorization of Payment Via Credit Card I give permission for ASA Summerfuel without further consent to charge the balance of my account in accordance with the payment preferences indicated on this form. I realize that if my son/daughter adds or drops any courses and/or options that my balance may change. Signature of cardholder: ___________________________________________________________________________ Questions About Your Account? Please contact our Accounts department at +1-212-796-8348. For our refund policy, please see the General Information section of the Summerfuel website.