Credit Card Payment Form

ADVERTISEMENT

CREDIT CARD PAYMENT FORM
Please type or print. If you, or a third party on your behalf, would like to pay by credit card, please enter your name (as you have
entered on this application) and your ICD file number (if known). Complete the cardholder information requested below. Enclose
this form with all other materials you are sending ICD.
1
Applicant name
____________________________________________ _____________________________________________
Given (first) and middle names
Surname (last/family)
____________________________________________ _____________________________________________
Phone Number
Email Address
2
ICD file number
3
Applicant birth date
(if known)
(Spell the month and enter numbers for the day and year)
_______________________________
_________________________ ____________ _______________
Month
Day
Year
4
Cardholder information
___________________________________________________________________________________________
Cardholder name (as it appears on card)
Cardholder billing address (For processing credit card payments only)
___________________________________________________________________________________________
Address
___________________________________________________________________________________________
Address
___________________________________________________________________________________________
City
______________________________________ _________________________ _________________________
State/Province
Post Code
Country
5
Credit card information
Credit card type (check one):
Visa
Mastercard
Discover
___________ - ___________ - ___________ - ___________
___________
Credit card number
CVV2 number
______ / _________
Expiration date:
Month
Year
$_____________________________________________
Total charges (US$) (see fee schedule)
6
Cardholder signature
(payment authorization)
I hereby authorize CGFNS INTERNATIONAL to charge my credit card for the total of all services requested in this application including any fee adjustments in
effect as of the date the order is received by International Consultants of Delaware. ICD is a division of CGFNS International.
___________________________________________________________________________________________
Authorized cardholder signature

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go