As we are updating the security on this website, payment will only be taken over the phone.

Please provide a number where you may be reached during business hours and our office will call you for your payment information or you may call us at 620-341-5407. There is a fee of $5 per set to mail the credentials for anyone not currently enrolled at ESU. Payment must be received before our services can be provided.
Please complete the following information to send your credentials.

E-Mail Address:

Today's Date:

Date of Birth : 

Name:

Maiden Name : 

Address:

City: 

State:

Zip:

Telephone # (required):

Graduation Date: 

Degree:

Major: 

PLEASE CHECK APPROPRIATE BLANKS BELOW:

Currently Enrolled At ESU?  

Expected Grad Date?

PLEASE PROVIDE CORRECT AND COMPLETE INFORMATION BELOW
FOR THE PEOPLE TO WHOM YOU WANT YOUR CREDENTIALS SENT:

Contact Person:

School USD/Firm:

Address:

City/State/Zip:

Email or Fax Number:

Position:

Contact Person:

School USD/Firm:

Address:

City/State/Zip:

Email or Fax Numgber:

Position:

Comments: