Credit Card Payment

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THE MALAHAT REVIEW
UNIVERSITY OF VICTORIA PO BOX 1700 STN CSC, VICTORIA, BC V8W 2Y2 CANADA
Phone: (250) 721-8524
Fax: (250) 472-5051
E-mail: malahat@uvic.ca (queries only)
CREDIT CARD PAYMENT
Name __________________________________________________________
Address ________________________________________________________
City _______________________
Prov/State _______ Code ___________
Country ____________________________
Telephone number: _________________________________
Email address: _____________________________________
For:
___ Long Poem Contest entry fee
___ Novella Contest entry fee
___ Constance Rooke Creative Non-Fiction Contest entry fee
___ Open Seasons Award contest fee
Rate (first entry):
__ Canada $35
__ United States $40
__ International $45
Add additional entries for $15 each (the same rate for Canada, United States, and International):
___ Number of additional entries
Total paid:
$ ____ Fee for first entry
$ ____ Fee for additional Entries: $15 x __ (Number of entries)
$ ____ Total to be charged to your credit card
__ American Express
__ MasterCard
__ Visa
__ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __
Expiry: __ __ / __ __
Signature______________________________ Cardholder Name ___________________
Note: The charge will appear as “University of Victoria” on your statement

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