Coastal Bend College
     Testing Department’s Payment Transaction Form

    [Please allow 1 to 24 hours (during business operational hours) to receive confirmation of payment and a copy of your receipt.  Response time will vary based upon volume of submissions] 

    This form needs to be filled out and submitted when an individual needs to pay for an exam and would like to make the payment through the internet so that they can schedule their exam through Coastal Bend College’s online scheduling site – Time Tap.  



    First Name of Examinee: 



    Last Name of Examinee: 



    Select the location where you will want to take your exam: 




     Select exam type & section/(s): 





    Select type of card: 




     Card Number - enter a dash between each 4 digits:


    (Ex: - _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _)  

     Expiration date – Month and Year 

    Enter two digits for the month / four digits for the   year: 
     (Example:  06/2019)

     Enter the security code – which is on the back of the card – 3 digits: 



     Enter the first and last name of the individual paying  the fee: 



     Enter the relationship to the examinee – if examinee is not the individual paying with their personal card & filling out this form. 



     Phone number of card user - include area code:                          


     (Ex:  ( _ _ _) _ _ _ - _ _ _ _)  

     Enter e-mail address of card user – we will e-mail a copy of the receipt and instructions to this e-mail: 



     Today’s Date: 

        [None] Select a Date Delete the Date 

     Today’s Time:   


    (Enter a.m. or p.m. after time - Ex:  1:13 p.m.) 



    Form created 6/12/18  
    Revised 8/7/19