VISA/MasterCard Charge Authorization Form

Complete and return this form with a photocopy of the front and back of the bank card.

1. Student's name:____________________________

2. Credit card: ____ VISA ____ MasterCard

3. Print the name of the card holder as shown on the front of the card.

Name of card holder:___________________________

4. Card number: ______________________________

5. Expiration date: __________

6. Indicate the fee(s) you want to pay and write the total amount:
________ $ 95.00 University ExpressSM Application Fee
________ $ 55.00 Express Mail Fee
________ $300.00 Conditional Admission Fee
________ Other: ______________________________

________ Total Fees

7. Read and sign.

I authorize the use of my bank card for payment of the fee(s) indicated above, in the amount of
$_________ U.S. dollars, to the Texas Intensive English Program.

________________________________________    ________________
Authorized signature of card holder                            Date

8. Fax to (512) 322-0592 or mail to:

   Texas Intensive English Program
   1103 W. 24th St.
   Austin, TX  78705
   U. S. A.

Click here to download the University ExpressSM Application Form