Get Study Abroad Form

Experience. Explore. Embrace the World. Cultural Study Abroad Registration Form Payment and Refund For all programs fees are due upon registration. Registration may be cancelled up to 1 weeks before the beginning date of the selected program and a refund of the program amount minus a 500 administration fee will be made. After that time no refund is available. Participants are strongly advised to purchase travel insurance that might cover them* If registration is made 1 weeks before the start of a program no refund is available. Fees for weekly experiences are based on one week increments per person daily rate is per day per person* You may choose multiple weeks. For more than four weeks or for groups please contact us. Enclose check or money order or complete credit card authorization below. Mail to the address or fax to the number below. Registration for Aix-en-Provence Rome One week 3000 Two weeks 5400 Three weeks 7650 Daily rate 500 How many days Address City State Zip Contact Phone s Contact E-mail Participant Signature Participant s Name Date of Birth Please indicated how you wish to pay Charge my card as indicated below or A check is enclosed for payment Credit Card Payment Authorization I authorize Ubiquity International LLC to charge my credit card as indicated below Type of card please check VISA MasterCard Discover Card Number CVN/CVV American Express Expiration Billing City State Zip Address if different than above Name as it appears on the card if different from above Authorized Signature Date The CVN is the three digit number on the back of a VISA MasterCard or Discover card printed after the card number. The CVV is the four digit number printed above the card number on AMEX cards. This number is used to prevent against fraud. Please note that the charge will appear on your statement as PAYPALUBIQUITY INTL* Check here to NOT receive the Ubiquity International email newsletter Please tell us how you heard about Ubiquity International* Family/Friend Gordon s Guide InfoHub Shaw Cultural Guides GoAbroad*com Cultural Traveler Search Engine Newspaper/Magazine Mailing Other For internal use Agent Received PO Box 21265 Piedmont CA 94620-1265 TEL/FAX 1-86 MY UI TOUR 1. 866. 984. 8687 info ubiquityinternational*com CST 2070359-40 WA SOT 602-549-382 www. ubiquityinternational*com Rev* 8. After that time no refund is available. Participants are strongly advised to purchase travel insurance that might cover them* If registration is made 1 weeks before the start of a program no refund is available. Fees for weekly experiences are based on one week increments per person daily rate is per day per person* You may choose multiple weeks. Fees for weekly experiences are based on one week increments per person daily rate is per day per person* You may choose multiple weeks. For more than four weeks or for groups please contact us. Enclose check or money order or complete credit card authorization below. For more than four weeks or for groups please contact us. Enclose check or money order or complete credit card authorization below. Mail to the address or fax to the number below. Registration for Aix-en-Provence Rome One week 3000 Two weeks 5400 Three weeks 7650 Daily rate 500 How many days Address City State Zip Contact Phone s Contact E-mail Participant Signature Participant s Name Date of Birth Please indicated how you wish to pay Charge my card as indicated below or A check is enclosed for payment Credit Card Payment Authorization I authorize Ubiquity International LLC to charge my credit card as indicated below Type of card please check VISA MasterCard Discover Card Number CVN/CVV American Express Expiration Billing City State Zip Address if different than above Name as it appears on the card if different from above Authorized Signature Date The CVN is the three digit number on the back of a VISA MasterCard or Discover card printed after the card number.