International Student Registration Fee

Order Information

Company name:	Customer ID:	New
First name*:	Last name*:
Phone:	Alt phone:
Email:	Alt email:
Student First Name*:
Student Family Name (Surname)*:
Parent/ Guardian First Name*:
Parent/ Guardian Family Name (Surname)*:
Country of Birth*:
Grade Level*:
Diocesan School Atending*:

Payment Information

Payment amount:
Recurs:
Payment date:

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Credit card accounts (optional)


Card type*:
Card number*:		CVV2 Code*:
Expiration date*:		What's This? CVV2 Code is the 4 digit number printed above your American Express Card account number on the front of your card or the last 3 digits of the number located on the back of your Discover, MasterCard, or Visa card. This number is not required, but you have the option to enter it as an additional security protection.
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Billing Address

Address 1*:
Address 2:
City*:
State/Province*:
Country*:
ZIP/Postal Code*:	Help Do not use spaces when entering ZIP/Postal Codes

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Terms and Conditions

I authorize the Catholic Diocese of Richmond to charge the credit card indicated in this web form, for the noted amount on today’s date. This payment is for the initial registration fee noted on the web payment form. I understand that refunds and cancellations are not permitted, however exceptions may be made on a case-by-case basis. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date.  I certify that I am an authorized user of this credit card, and that I will not dispute the payment with my Credit Card Company, so long as the transaction corresponds to the terms indicated in this web form.

I accept the terms and conditions

CDR Office of Catholic Education
7800 Carousel Lane
Richmond, VA 23294
(804) 622-5117
rburrill@richmonddiocese.org
http://www.richmonddiocese.org/catholiceducation

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