UNITED STATES EMBASSY - LONDON VISA BRANCH by leader6

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									                     UNITED STATES EMBASSY - LONDON
                               VISA BRANCH
                     Credit Card Payment Form for Visa Issuance Fees

Nationals of certain countries are required to pay an issuance fee in order for an approved visa to be issued. Fees
are based upon reciprocity. From the information you have provided, it appears that you will be subject to an
issuance fee if your application is approved. If you would like to pre-authorize payment of the fee, please complete
this form and include it with your application. Please consult our website (http://london.usembassy.gov ) for a
complete list of visa reciprocity schedules or call 09042-450-100 (calls cost £1.20 per minute).

If your application is denied, this form will be returned to you and no charge will be assessed.

 CREDIT CARD              American          Diners              Discover          Mastercard           Visa
 TYPE: please tick      Express          Club

              DEBIT CARDS AND OTHER CREDIT CARDS CANNOT BE ACCEPTED

CREDIT CARD NUMBER:



EXPIRATION DATE
(MONTH/YEAR):

EXACT AMOUNT IN U.S.
DOLLARS TO BE DEDUCTED
FROM CREDIT CARD
                                      (in figures)                (in words)
Please note that the visa issuance fee is charged per visa applicant and will be deducted in
dollars from your credit card

FULL NAME AS SHOWN ON
CREDIT CARD


SIGNATURE OF
CARDHOLDER:


                   For NIV Office Use Only
                                                            Service         Country        Visa       Unit
                        Name                      Qty                                                          Total
                                                             Code            Code          Class      fee




NIV030a
August 2009

								
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