Payment Fax Form
(734) 763-4917

To: The Career Center
Attn: Counseling and Assessment Services Payment

Assessment Options and Career Counseling Appointments. To fax your payment please print this form, circle/provide the appropriate information, and fax to 734/763-4917. Thank you.


Services/Programs 		Student/ New Grad
Alumni/ae
Community
Career Counseling
Counselor Name:
$15.00 $40.00 $60.00
Individual Assessment MBTI $15.00 $90.00 $120.00
Individual Assessment SII $15.00 $90.00 $120.00
FOCUS $15.00 $50.00 $60.00

Request Programs
Program Date:

 $15.00 $50.00 $70.00
Other      

Credit Card Information

Name on Card Cardholder Address
E-mail Phone #
Credit Card Number Expiration Date (mm/yy)
Signature of Card Holder Total Amount to be Charged