Institute of Modern Spanish: Spanish language studies Merida, Yucatan, Mexico http://www.modernspanish.com If you wish to use credit card payment method, please print, fill in, and sign this form and include it with your registration form. Both forms -- registration form & this credit card payment form -- should be mailed to: Institute of Modern Spanish ATTN: Janese Ceron 413 Interamerica Blvd. WH1 PMB MX 18-108 Laredo, TX 78045, USA or faxed to U.S. fax number: (775)-213-0406 Please contact our us to verify your total amount due. U.S. office toll free 1-877-4MERIDA (463-7432) or e-mail 2learn@modernspanish.com. I, ___________________________ (print your name), give the Institute of Modern Spanish permission to charge my Visa / MasterCard (circle one) in the amount of US$________________ to cover my registration deposit for a _____-week (write number of weeks) study program in Mérida, Mexico. I understand that this form authorizes the Institute of Modern Spanish to charge the US$100.00 deposit to my card upon receipt of this form. The balance will be due on my Monday start date. My Monday Start date is: _________________________________________ Credit Card Number _____________________________________________ Expiration Date _____ / _____ Signature ___________________________________ Date ______________ Street address of card holder including city, state, & zip (billing address): Street ________________________________________________________ City ______________________ State ____________ Zip _______________ Telephone Number (______) ___________________ © 1995-2004 Instituto de Español Moderno