University of Evansville : Admission Deposit

You are about to request that a payment of $300.00 be deducted electronically from your credit or check card. Please complete the following form and review the payment agreement below. All the fields below are required.

Student Information:
Student's Social Security Number:
Student's First Name:
Student's Last Name:
Card Owner Information:
First Name: (as it appears on the card)
Last Name: (as it appears on the card)
Street Address:
City:
State:
Zip Code:
Home Phone:
E-mail Address:
Card Type:
Card Number: (no spaces or dashes)
Expiration Date:

Payment Agreement:

You authorize the University of Evansville to initiate a charge to the above specified credit or check card for $300.00. Your credit or check card statement will reference "U OF E BUSINESS OFF" as the payee.

You affirm that:

I have read, understand and agree to be bound to the terms of this agreement;
I am authorized to perform transactions using the card information above;
I accept the terms of this agreement and certify, under penalty of law, that the information provided above is correct.

Should this transaction fail for any reason (including invalid account numbers, chargeback etc.) you understand that additional penalties, fees and interest may accrue.

Click the "Verify Your Information" button to continue.