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Application for King's Online Dual Enrollment and Single Elective Classes

Personal Information

First Name*	ABOUT SSL CERTIFICATES
Middle Initial
Last Name*
Address *
Apt #
City*
State/Province*
Postal Code*
Country
Home Phone*	--
Cell Phone	--
Gender*	Female Male
Birth Date*	//
Ethnicity
E-Mail Address *
I am applying for*
Will you be a High School student while taking this class? Yes No
Name of HS
HS City
HS State/Province
HS Postal Code
Your Current Class Year*

Summer 2013 Course(s) for Which You are Applying ($800 per course)

Course 1
Course 2

Credit Card Information

Name on Credit Card*
Billing Address*
City/State/Zip*	,
Card Type*
Card Number*	(enter all digits with no spaces or dashes)
Card Expiration Date*	MM/YY

Note: When you click Continue, your credit card will be billed for $800 per course as chosen above if you are a high school student. Otherwise, your will be charged $1750 per course. You will be emailed a receipt. Please keep that email as proof of payment. If you were sent a discount code, enter it here: * Indicates required fields.