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CREDITDEBIT CARD PAYMENT REQUEST

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CREDITDEBIT CARD PAYMENT REQUEST Powered By Docstoc
					Examinations Office
Date: ........................

Credit/Debit Card Payment Requests – Postgraduate Re-examination fee
(please note we can not accept American Express card)
Card Holder Account Number (16-18 digit number across front of card) Issue Number (if applicable) _ _ / _ _ Card expiry date _ _ / _ _ Card Valid From date (if applicable) _ _ _ Last 3 digits from card signature strip _ _ _ _ ( ) _ _ _ _ _ _ _ _ _ _ _ _

RE-EXAMINATION FEE (delete as appropriate)

Masters MPhil PhD

£70.00 £120.00 £150.00

Name and address of cardholder

Contact telephone number Student name University of York student number Student date of birth For office use only:
Account 4035 Analysis Code Workorder 50005201 Reference Re-examination Fee TOTAL Gross Amount £

Fax to the Examination Office on ++44 (0)1904 434039 Or return to Examination Office, University of York, York, YO10 5DD


				
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