--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Please print out this form, and either: FAX toll-free to 1-866-463-2361 [or] MAIL to 14 Central Park Drive, Ottawa ON K2C3Z9 Canada
CREDIT CARD PAYMENT BY FAX / MAIL
INVOICE/JOB NUMBER Card Type (circle one) Payment Type (check one) Visa Deposit Invoice Balance Name on Card Card Number Expiry Date (month / year) Card Verification Number | Mastercard
preferred
|
American Express
preferred
Billing Address ** must match the address on your credit card statement Address City State/Province Zip/Postcode Country Phone Number
PAYMENT AMOUNT Currency (circle one) CDN$ | USD$ | AUD$ | GBP£
Amount may be tranferred to $CDN at local exchange rate (by TD Canada Trust) but will appear on your credit card statement in your local currency.
Email
You will receive notification/receipt by email once your payment has been received and approved.
Affirmation and Signature
I hereby confirm that all information provided in this form is accurate, and that I am the legal holder of this credit card or am authorized by the legal credit card holder to approve this transaction.
Signature
Printed Name