ELC credit card form

DREXEL ELC CREDIT CARD PAYMENT FORM

For application fee payments ONLY.

Fill out this form and then print it out - you will NOT be submitting any credit card information through the Internet.

Send the form by fax to: 215-895-6775

Or mail to:
Drexel ELC
229 N. 33rd Street
Philadelphia, PA. 19104 USA

DO NOT EMAIL OR SEND AS A PDF.

Date
Student's Name
Amount Charged to Credit Card: $100

Type of Card: Mastercard American Express
(We cannot accept Visa card payments.)

Cardholder's Name (as it appears on the card)

Cardholder's Signature

Account Number

Expiration Date

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