Tier 3 Order Form

Name*

First Last

Your school login email address*

Phone

Is your name different in the Student Database?*

Yes
No

Student Database Name

First Last

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this your shipping address?*

Yes
No

Shipping Address (Leave Blank if same as Billing)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Select Item*

Custom Diploma Cover ($25)*

Yes
No

The Christian Leaders staff will verify your diploma level before fulfilling the order. Orders for award levels that have not been met will be refunded.

Total

$0.00

Payment Options*

I Want to Pay Using PayPal (You will be transferred to the PayPal Website to Complete Your Transaction)
I Want to Pay Using My Credit Card

Credit Card*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name