Credit Card Payment Form

Credit Card Payment Form Name:............................................................................................................... Address:……………………………………………………………………………………………….……… Date of course: ……./……/………….... Course: ………………………………………………………………………………………………………… Name of Participant: ………………………………………………………………………………………………………………………. Name on card: ……………………………………………………………………………………………... Contact Number: ………………………………………………………………………………………….. Amount: $.........................Invoice Number: ……………………. Charge Type (please tick): Deposit

Paid in Full

Part Payment

Signature of Card Holder: …………………………………………………………………………… Please email this form to [email protected] or Fax it to 03 5625 5822 ----------------------------------------------------------------------------------------------------------Card Type (circle):

Master Card

Visa

Amex (Extra 3.0%)

Card Number:

Expiry Date: WAM Training – credit Card Payment Form

CCV: Version 2.2 (Doc No. 026) February 2012