Credit Card payment request

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					                         ATA Carnet
                         and Document Certification                                                     Credit Card Payment Request

DATE

                                                                                                           month                   day                   year

                                                                                                          VISA                 Mastercard              AMEX
CARD (Please check one of the following)

CARD NUMBER

CARD HOLDER NAME

NOTE: Canadian Chamber policy is to refund security deposits by cheque in the name of the individual or company on the Carnet document. If you wish for the
refund to be in a different name, the request must be made in writing at the time of the return of your carnet document for review and closure.

CARD HOLDER TELEPHONE NUMBER

CARD EXPIRY DATE
                                                                                                                                                        month                   year
DESCRIPTION OF PURCHASE/SERVICE

                        ATA Carnet                                                                   Document Certification

Document Certification Fees                                                                                                $                                                            -

Carnet Fees (incl. rush)                                                                                                   $                                                            -

Additional Carnet Counterfoils (incl. rush)                                                                                $                                                            -

Courier Fees ($25.00, if using CCC courier)                                                                                $                                                            -

                                                                                   SUBTOTAL (Taxable Items) $                                                                           -

                        GST on purchase = 5% X Fees (AB, SK, MB, PEI, NT, NU, YK, QC)
                                                                                                        GST#106844285      $                                                            -

                                               QST on purchase = 7.5% X (Fees + GST) (QC only)
                                                                                                      QST#1006090296       $                                                            -

                                                       HST on purchase = 13% X Fees (ON, NL, NB)
                                                                                                       HST#1006090296      $                                                            -

                                                            HST on purchase = 12% X Fees (BC only) $                                                                                    -

                                                            HST on purchase = 15% X Fees (NS only) $                                                                                    -

                                                                                              SUBTOTAL (Taxes) $                                                                        -
Security (40% of the value of the goods, non-taxable); or                                                                  $                                                            -
AON Bond Premium (non-taxable)                                                                                             $                                                            -
                                              TOTAL OF CHARGE = Fees/Courier + Taxes + Security
                                                                                                                           $                                                            -


Card Holder Signature

                                                            To be filled out by the issuing department
Carnet Holder/Company Name

Carnet No. or Type of document certified
Pre-Authorization Number /
                                                                                                                                                       8500-
  Department Account Code

Clerk Signature / Date
                                                                                                                                 month                    day                   year

Any personal information provided on this form will be used by the Canadian Chamber of Commerce, as set out in our Privacy Policy, to conduct the transaction indicated on this form. Please
consult our Privacy Policy, available on-line at www.chamber.ca or contact our Privacy Officer at privacy@chamber.ca or 613-238-4000 x 229.




                                                                                                                                                                                            Rev. Oct '12

				
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