Payment Submission - Be Well Solutions Dietetic Internship

Payment via Credit Card or eCheck?*
- Credit Card (a 3.5% processing fee will be added to your payment amount)
- eCheck (no fee)
Please enter the amount you wish to pay:*
Total payment after fees:
Price: $0.00
Name:*
First Last
Applicant/Intern Name (if different from above):
First Last
Date of Birth:*
MM slash DD slash YYYY
Email:*
Phone:*
Billing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
eCheck:
Name on Account Bank Name Routing Number Account Number Account Type
Credit Card:*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name