Application Fee Payment

Pay Application Fee

Instructions:

Fields marked with an asterisk (*) are required.
Ensure your first name and last name match the names on your application.
The billing address must be the address on file with your bank or credit card company.
Please double-check your information before submitting. Payments are non-refundable, and incorrect details may delay your application.

Applicant Information

* First Name

* Last Name

* Email Address

* Phone Number

Payment Amount

Application Fee

$35.00

Total:

$35.00

Payment Information

Credit Card
Bank Account (USA only)


* Card Number:	(enter number without spaces or dashes)
* Expiration Date:	(mmyy)
Card Code:	What's this?

Bank Name:
* Bank Account Number:	(enter number without spaces or dashes)
* ABA Routing Number:	What's this?
Name On Account:
Bank Account Type:

Billing Information

* First Name

* Last Name

* Address

* City

State

* Zip Code

* Country

* Email

* Phone

Security Check

* Please do NOT click the "Pay Now" button more than once.
* Please do NOT Refresh/Reload the page after clicking the "Pay Now" button.
* By clicking the Pay Now button, you authorize UCHA to charge you for the amount specified in the Application Fee field by using the Payment and Billing Information you provided above.