MBU ROAD TRIP INFORMATION

Destination MBU Road Trip Registration

More information available at: https://www.mbu.edu/roadtrip

Basic Information

First Name

Last Name

Email

Phone Number

Gender

Address

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Parent's Information -For emergency contact

First Name

Last Name

Phone Number

Email

School Information

School Name

School Year

Location Pick Up

Dorm Requests

Name of the MBU student you would like to room with.

Major/Minor of Interest:

Degree, major, career, etc.

Please provide any additional comments regarding your visit:

If you have any questions about your visit, please email welcome@mbu.edu or call us at (920) 206-2370.

Payment Amount:

Payment Information

Customer Details

First Name

Last Name

Organization Name

Email Address

Phone Number

Billing Address

Street

City

State

Zip

Country

NOTE: There are no transaction/convenience fees for credit card payments.

Payment Method

Credit CardeCheck (USA Only)

Credit Card Details

Name on Card

Card Number

CVV

Expiration Month

Expiration Year

NOTE: You have chosen a non-USA billing address and the eCheck payment method. Your eCheck payment will not be able to be processed from a non-USA bank account.

Bank Account Details

Account Holder Name

Bank Name

Account Type

Account Number

Routing Number

Confirm Account Number

Confirm Routing Number

Account Numbers Match?

Routing Numbers Match?

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