Name_____________________________________________

Program/Selection: __________________________________

Mailing Address:_____________________________________

Email Address:______________________________________

Phone Number:  _____________________________________

Fax Number:________________________________________

Occupation:  ________________________________________

Prior Education/Degrees/Certifications___________________

__________________________________________________

Address of Card Holder:_______________________________

Credit or Debit Card Number____________________________

Expiration Date on Card_______________________________

Three Digit Number from Back of Card:____________________

Or

Name on Checking Account:  ___________________________

Bank Routing Number From Check: ______________________

Bank Account Number:  _______________________________

I authorize payment of $98 annually for membership in Regus University and The American Colleges.  Please initial here  _____

I authorize Regus University and The American Colleges to charge my credit card, debit card or my checking account for the payment method checked below.  Please initial here  _________

A.  Discounted tuition after $3,000 Tuition Scholarship:         

Master     =   $6,193    ____
Doctor     =   $7,193    ____

B.  Payment plans are available by special arrangement.  Just add $50  service charge to each installment.
                               
C.  Membership Fee of $98 is in addition to tuition.

1.  The annual membership fee of $98 is nonrefundable.

2.  Once the Proprietary Program Guide has been released to the student, there is no refund.

I agree with all of the above terms and conditions.  Please enroll me as a member of the American Colleges.

__________________________       Date:  _______________

               Sign Your Name

www.regusu.org