Instructions: Print this form and submit with application if paying fees with a credit card.

Virginia Tech Research and Graduate Stu
dies Graduate School
Sandy Hall
Virginia Tech
Blacksburg, VA 24061-0325
+1 540 231 6691     fax: +1 540 231 3714

To pay the non-refundable application fee of $45 by credit card, please complete this form and append it to the complete application form.

Studentís Name: ______________________________________________________

Credit Card Number: __________________________________________________

Expiration Date: _____________________________________

 Master Card  Visa Card

Card Holder Signature: __________________________________________________