New Credit Recovery Payment Form

Enroll and Pay Credit Recovery Classes Online
Student you are paying for?
Student Name *

First Name Last Name
Date of Birth *

/ Month / Day Year
Last 4 of Social Security Number
Sex *

Male Female
Last 4 of Social Security Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
E-mail
What Classes Section (A or B) the student will take for Credit Recovery *
What are you paying for? Tuition, Credit Recovery
Parent Information *

First Name Last Name
What Class(es) are you paying for?
What Class(es) are you paying for?
Parent Email Needed to Monitor Student(s)
Phone Number *

- Area Code Phone Number

Which School do you want your classes sent? Name, City and State
Please provide your school information to send your credits.
Name of School *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date School Needs Your Transcript

/ Month / Day Year
Which School do you want your classes sent? Name, City and State
E-mail
Select Which you prefer *

Test Review and then Test Take Lessons

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Upload your Parent ID or Fax to TSA
Parent / Guardian Type Name to Enroll Your Child *

First Name Last Name
Parent/Guardian Type Your first and Last Name to Enroll Your Child/optional signature *
Signature Use Mouse, figure or pen depending on your device

Enter amount: *

Amount Due *

USD Tuition and Fees .30 + 2.9%

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Amount Charged
Should be Empty: