"Credit Card Payment Authorization Form" - British Columbia, Canada

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Download "Credit Card Payment Authorization Form" - British Columbia, Canada

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Credit Card Payment
Authorization Form
Please use this form to authorize the use of a credit card for a fee payment.
(Note: Certificate holders who are in default of paying the annual practice fee are subject to the addition of a $30 late
fee if the fee is received between June 1 and June 30, and a $60 late fee if the fee is received between July 1 and
October 31.)
Applicant’s/Certificate Holder’s name:
File/Certificate #:
Name of individual, agency or business as it appears on the credit card (please print):
I authorize use of the credit card indicated to pay the fee(s) for the applicant/certificate holder named above.
Total Payment Authorized
Date (YYYY/MM/DD)
$
In the event that we need to get in touch with you, please provide us with your contact information:
Address:
Home Phone:
Work Phone:
Email address:
AUTHORIZATION FOR CREDIT CARD USE
American
Master
Visa
Card Number
Express
Card
Expiry
I authorize the Ministry to charge
$
to the credit card number shown above.
/
(Amount in CDN$)
(MM/YY)
Printed name as it appears on credit card
Cardholder’s signature
Please note: The credit card information provided on this form will not be retained. Upon authorization of the payment
request, all credit card information will be destroyed. Credit card data should not be emailed. Please fax to the Ministry
of Education at 604 775-4859 or mail to the address below. The easiest and fastest way to pay your annual fee by credit
card is by entering the secure Your Account area online.
February 2020
Ministry of Education
Mailing Address:
Telephone: 604 660-6060
400-2025 West Broadway
Toll Free: 1 800 555-3684
Vancouver BC V6J 1Z6
Facsimile: 604 775-4859
Credit Card Payment
Authorization Form
Please use this form to authorize the use of a credit card for a fee payment.
(Note: Certificate holders who are in default of paying the annual practice fee are subject to the addition of a $30 late
fee if the fee is received between June 1 and June 30, and a $60 late fee if the fee is received between July 1 and
October 31.)
Applicant’s/Certificate Holder’s name:
File/Certificate #:
Name of individual, agency or business as it appears on the credit card (please print):
I authorize use of the credit card indicated to pay the fee(s) for the applicant/certificate holder named above.
Total Payment Authorized
Date (YYYY/MM/DD)
$
In the event that we need to get in touch with you, please provide us with your contact information:
Address:
Home Phone:
Work Phone:
Email address:
AUTHORIZATION FOR CREDIT CARD USE
American
Master
Visa
Card Number
Express
Card
Expiry
I authorize the Ministry to charge
$
to the credit card number shown above.
/
(Amount in CDN$)
(MM/YY)
Printed name as it appears on credit card
Cardholder’s signature
Please note: The credit card information provided on this form will not be retained. Upon authorization of the payment
request, all credit card information will be destroyed. Credit card data should not be emailed. Please fax to the Ministry
of Education at 604 775-4859 or mail to the address below. The easiest and fastest way to pay your annual fee by credit
card is by entering the secure Your Account area online.
February 2020
Ministry of Education
Mailing Address:
Telephone: 604 660-6060
400-2025 West Broadway
Toll Free: 1 800 555-3684
Vancouver BC V6J 1Z6
Facsimile: 604 775-4859