CUIrvine

CAMPAIGN LOGO OR IMAGE

Passenger Information

First Name

Last Name

Mobile Number

Address

City

State

Zip

Passport Name

Gender

Passport: I/we have (or will have by 3/1/25) a valid US passport the expires no earlier than 8/1/25 and will provide a copy of the photo page to Concordia.

Which of these best describes your travelling status?

Second Passenger Passport Name

Second Passenger Gender

I agree to pay the single room supplement.

I will allow Concordia to share my contact info with other solo passengers of my gender to explore roommate options. If we do not share a room, I agree to pay the single room supplement.

Name of other passenger

Payment Amounts

$258.75 registers one passenger. $517.50 registers two passengers. Please mail a check for the full balance ($3,000 per passenger) ASAP.

$3,363.75 pays the full current balance per passenger including credit card fees.

An additional $500 is due per person ($517.50 with credit card fees) by Feb 14.

I have read the payment schedule. I understand that credit card payments will require an additional 3.5% processing fee. Email [email protected] for instructions on how to send payments by check.

This is a secure 256-bit SSL encrypted payment

Card Number

CVV

Donor hereby approves the payment of the donation and/or purchase to Concordia University Irvine and in the amount set forth herein.

Passenger Information

Payment Amounts

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