Office of
Continuing Education
Payment
form
TERM: _______________
GCC Continuing Education
Term:
_____________ Course Title:
__________________________ Cost:
________
Term:
_____________ Course
Title: __________________________
Cost: ________
REVENUE BAC #:______________________________
Date: ____________________________ Program:_______________________________________
Name: ____________________________ Social Security #: ________________________________
Address: ___________________________________________________________________________
E-Mail Address: _____________________ Contact #: (H)_________________(W)_______________
Form of Payment: CASH CHECK CREDIT CARD
DEFERRED (Please Specify): _________________________________________________________
Payment Amount Received:_____________ Receipt #:_____________________________________
REMARKS:________________________________________________________________________
__________________________________________________________________________________
Disclaimer: Due to technical difficulties, access to your student billing account is not possible at this time. Students are still obligated to pay outstanding balances that may exist but are not reflected herein.
I, _________________________ understand that if in the event I have an existing balance forward
Student’s Name
from a previous semester, I will be disenrolled from the current semester ___________________.
_______________________________________ ___________________
Signature (Student) Date