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:	$16.00	$75.00	$100.00
Individual Assessment MBTI	$16.00	$115.00	$150.00
Individual Assessment SII	$16.00	$115.00	$150.00
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