Credit card payment authority form

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					                      Credit card payment authority form
I, (your name)____________________________________________ hereby authorise the Centre for
English Language in the University of South Australia (CELUSA) to debit my credit card, as outlined
below.


IELTS candidate

Family name             ______________________________________________________________

Given name(s)           ______________________________________________________________

Date of birth           ______________________________________________________________



Amount (select one)

                         $317*                              $348* including GST
                        IELTS Test Fee                          IELTS Test Fee
                        (if you are paying)                     (if your company is paying)

                         $176*                              $20*
                        (remark – EOR)                          (per copy, additional TRF’s)

                         $79* administration fee*



Credit card details
* All credit card payments will incur a 1.5% credit card payment surcharge

Visa / MasterCard / Bankcard (please circle one only)

Credit card number      ____________________________________            Expiry date _______________

Name on card            _________________________________________________________________

Printed name            _________________________________________________________________

Signed                  _____________________________________           Date______________________


                        Please include this form with your IELTS application

				
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