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CREDIT CARD PAYMENT AUTHORIZATION IELTS EXAM only by act50979

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									                                                     Global Village English Centres – Vancouver
                                                                      Official IELTS Test Centre
                                                                               IELTS Administrator: Loretta Revoczi
                                                                                                 888 Cambie Street
                                                                                   Vancouver, BC - V6B 2P6 Canada
                                                                       Tel.: +1 604 569 3494 - Fax: +1 604 684 2124
                                                                                    E-mail: info@ieltsvancouver.com
                                                                                   Web site: www.ieltsvancouver.com



CREDIT CARD PAYMENT AUTHORIZATION
IELTS EXAM only
I hereby authorize Global Village Vancouver to charge my credit card for

_________________________, ____________________’s payment.
student’s last name                        student’s first name

Card Holder’s Name: _________________________, _____________________.
                            last name                                   first name

Credit Card: □ Visa          □ MasterCard

Credit Card Number: __________-__________-__________-__________.

Expiry Date: ______/______.
                  month / year

Security code: _____ (last three digits on back of card)

Amount: CDN$ _______________.

Card Holder’s Signature: ______________________________.


-------------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE

ID# __________ Test Date: ___________

Test Fee $________
Postage $________
Specimen materials $________
Postage $________

IELTS Exam $_________


Other _______________

								
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