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6/19/2015 DepartmentofHomelandSecurityFormI901ApplicationPaymentInformation
https://www.fmjfee.com/i901fee/desktop/students/creditcard.htm 1/1
StudentandExchangeVisitorProgram:SEVISI901Fee
CardholderName:Total:CardType:CardNumber:ExpirationDate:CardholderStreetAddress:CardholderCityProvince:CardholderState:CardholderZiporPostalCode:CardholderCountry:
Isthisinformationcorrect?
Iunderstandthisisanonrefundablefeeunlessithasbeenpaidinerror.
Bypressing"Yes",Iunderstandmycreditcardwillbechargedforthefeeamountlistedabove.
ApplicantName:
PaymentInformationPaymentInformation:
RAVIPARKASH
RAVIPARKASH
$200.00
Visa
*4384
01/2018
#3139,SECTOR55CHANDIGARH
CHANDIGARH
160055
INDIA
WEACCEPT
OMB16530034(Expires05/31/2018)
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