Fill out this form to pay for your BTW lessons. Student Name* First Middle Last Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Phone*6 Hours BTW* Full Payment $205.00 ($185+$20 one-time gas fee) Payment Plan - 1st payment $107.50 ($97.50+$10 1/2 gas fee) Payment Plan - 2nd payment $107.50 ($97.50+$10 1/2 gas fee) Due to the current gas prices, we have implemented a one-time gas surcharge feeTotal $0.00 Credit Card* DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name Parent Signature: I agree to the terms listed below.* First Last REFUND POLICY - There is a $10 fee for all refunds.To help avoid SPAM, What is 4+2=*Please enter a number from 6 to 6. Δ
