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Summerfuel General Payment Form 2016 (1)

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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: finance@summerfuel.com
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. 
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