eCampus Course Enrollment Form

Student’s Name:  ___________________________________________

Address: __________________________________________________

City, ZIP ___________________________________________________

Phone: ____________________________________________________

Email   ________________________________________________

Application Fee (one time fee)                   $50.00                                               _____________

Enrollment Fee (per semester)                     $25.00                                            _____________  

Tuition per 3 credit hour Course         $125.00 x ______                                _____________   

__________________________     $______ x ______ _____________

Check #____________    Cash $ ____________                           TOTAL DUE:             _____________

Credit Card #____________________________

exp ______              Received:   _____________