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Shaker Mountain Opera
2005 Program Tuition and Fees Payment Form

(please print or type)

Participant Name: _____________________________________

Billing Information:

First Name:   Last Name:  
Billing Address:  
City, State, ZIP:  
Email Address:  
Country:   Telephone: (_______)
Please check here ___ if you are paying by check and indicate check number and amount: _________________

Please check here ___ if you are paying by credit card and indicate amount to be charged: _________________
Credit Card No.:   Expiration Date:
Credit Card Type:
(please circle one)

MasterCard

 

Visa

 

              American Express

 
Signature:
(as shown on card)		   Date:

Please indicate charges below (check all that apply). All amounts are shown in U.S. Dollars.

 Tuition/Fees:

Total Amount:
____ Application fee ($30.00) Non-refundable  $

___ Tuition- July 11th - August 8th ($3700) Based on Room and Board

          (breakfast and dinner) and all classes.

  $

(There will be no refunds after April 15th 2005)   Total Amount Due:

 $

Please print this page.
Enclose the completed form, including your signature if paying by charge,
 with your other registration materials.