Payment Form - Our Lady of Mercy Academy

Student Name(Required)

First Last

Student OLMA Email(Required)

College Name(Required)

College Address(Required)

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

Type of Application Submitted

Please select only one(Required)

Deadline Dates

Please indicate only one(Required)

College Deadline Date(Required)

Letters of Recommendations

Please list in priority order; your counselor's letter will automatically be sent

Teacher #1(Required)

Teacher #2(Required)

Additional Comments

Major(Required)

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Comments

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First Quarter Grade Request Form

Our Lady of Mercy Academy will send first quarter grades ONLY to schools that request them. Please provide documentation from the college to substantiate the need for quarter 1 grades. Please attach documentation below. Please allow 7 business days for processing.

Student Name(Required)

First Last

Student Email(Required)

College Name(Required)

Documentation(Required)

Please attach either an email or screenshot of your portal

Max. file size: 128 MB.

Admissions Office Phone Number(Required)

Admissions Office Email(Required)

College Representative (Long Island) Name(Required)

College Representative (Long Island) Email(Required)

Admissions Office Fax Number

Comments

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Scholarship Application Request Form

Please fill out a separate form for each scholarship, and indicate whether you will be submitting your application separately in the Comments section. Please allow 7 business days for processing.

Date(Required)

Student Name(Required)

First Last

Student OLMA Email(Required)

Name of Scholarship(Required)

Scholarship Address(Required)

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

Scholarship Deadline(Required)

How is application being submitted?(Required)

Please be specific ie electronically, mail, etc

Scholarship Contact Name

Scholarship Contact Email

Please indicate what OLMA needs to submit

(please check all that apply)

Transcript

College Counselor Letter of Recommendation

Teacher Letter of Recommendation

Report Card

Scholarship Application

Any additional information

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Name(Required)

First Last

Maiden Name

Email(Required)

Address(Required)

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

Cell Phone(Required)

Home Phone

Affiliation(Required)

Graduation Year

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Email

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Name(Required)

First Last

Class of(Required)

Email(Required)

Phone(Required)

News(Required)

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If you wish to pay via check, please make checks payable to
Our Lady of Mercy Academy (MPTO in the memo)

Mail Membership Form and check to
Attn: MPTO (Membership) Our Lady of Mercy Academy 815 Convent Road Syosset, NY 11791

Parent's Information

Name(Required)

First Last

Name

First Last

Address(Required)

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

Phone

Email(Required)

Daughter's Information

Name(Required)

First Last

Grade(Required)

MPTO Annual Membership Fee

This fee is per family.

Price:

Billing Information

Credit Card(Required)

Card Details

Cardholder Name

Billing Address(Required)

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

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Name

This field is for validation purposes and should be left unchanged.