Keio Academy of New York—Payment Information

Program Fee for Keio Academy of New York Summer Program

Student Name  * First Name: Last Name:
Amount * US$ (Please write the exact amount indicated in the e-mail.)

 * required item

Billing Information

Name * First Name: Last Name:
E-Mail * ex:
Street Address *  ex: 3 College Road
City  *  ex: Purchase
State *  ex: NY
Postcode  *  ex: 10577
Country *  ex: USA
Phone Number *  ex: 03-1111-1111
Fax Number  ex: 03-1111-1112

 * required item