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Credit Card Payment Form


Please complete this form when paying the examination fee and the testing center service fee
with a MasterCard or VISA. Return the completed form with the registration form.
Print clearly or type the information in the space below.

Payment Information:

     
Breakdown
__ Please charge my VISA a total of    $____________    
     
$50.00
  $25.00
__ Please charge my MasterCard a total of    $____________
MAT
  WPU

 

Credit Card Number:   Expiration Date:
     
___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___  
_______ /_______
   
        month/year


__________________________________________________ ___________________
Signature of Cardholder Date

 

Examinee Information:

_______________________________________ __ __ __ - __ __ - __ __ __ __
Name of Examinee Social Security Number

_________________________________________________________________________ _________________
Address                                               City                  State                        Zip Telephone



If you have any questions, please contact the Office of Testing, William Paterson University at 973-720-2570.

Office of Testing Telephone:  973-720-2570
William Paterson University Fax:  973-720-2588
300 Pompton Road, Wayne, NJ  07470 email:  officeoftesting@wpuj.edu