Student or Post Grad Information (Items in RED must be filled in)
Student Name:
Seminary:
Mailing Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####    FAX ###-###-####
Student E-mail:	Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                      no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                      no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                      no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                      no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                      no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                      no dashes
Billing Information (Items in RED must be filled in)
Name:
Street Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####
FAX:	###-###-####
Your E-mail:
Credit Card Information
Credit Card:	(No spaces or dashes)      EXP DT: (MM/YY) We accept  VISA/Mastercard
Card ID #:

Add the appropriate Post Grad/Dependent Plans
Qty	Type	Description / Price
	Post Graduate Student	Select a Post Grad Plan and Term ------------------------------ Post Graduate - 1st Semester - 09/01/07 to 02/28/08 - $1725 Post Graduate - 2nd Semester - 02/28/08 to 08/31/08 - $1725
	Spouse	Select a Spouse Plan and Term ------------------------------ Spouse - 1st Semester - 09/01/07 to 02/28/08 - $1719 Spouse - 2nd Semester - 02/28/08 to 08/31/08 - $1719
	Child	Select a Child Plan and Term ------------------------------ Child - 1st Semester - 09/01/07 to 02/28/08 - $1099 Child - 2nd Semester - 02/28/08 to 08/31/08 - $1099

Other Questions, Comments, or Requests: