Babbage Net School Application P.O. Box 517, Port Jefferson, NY 11777 --------------------------------------------------------------------------- Name _______________________________________ Address _______________________________________ _______________________________________ _______________________________________ Phone Number (_____) _____-__________ E-mail _______________________ School ________________________________________ ________________________________________ ________________________________________ ________________________________________ School Contact Person _________________________ Course(s) Tuition ________________ _____________________ ________________ _____________________ ________________ _____________________ ________________ _____________________ ________________ _____________________ Screen Name ______________ Passsword _______________ (all lower case and 5 to 12 characters) Payment Schedule: Check your choice of payment and enclose with application ____ 1) One payment. ____ 2) Or 2/10 of the total tuition for first month and 1/10 of the total tuition for 9 months Discounts will be applied based on number of course enrollments. Payment Type: ____ 1)Check: Number ________ Amount ________ ____ 2)Credit Card: Name on card _________________________________ VISA __ MasterCard __ American Express __ Card Number: ________________________________ Expiration Date: _____ _____ Signature: __________________________________ ____ 3) Purchase Order Number __________