Credit Card Payment Form printable pdf download

Credit Card Payment Form

ICANN will accept Visa, Mastercard (Maestro), AmericanExpress, and Discover credit card payments for invoices

not exceeding US $20,000 for ICANN fees and contributions.

Please print and completely fill out the following form to ensure timely processing. Credit card and address

information is confidential. The completed form should be faxed or mailed to ICANN at:

FAX: +1-310-823-8649 or

MAIL: Internet Corporation for Assigned Names and Numbers (ICANN)

12025 Waterfront Drive, Suite 300

Los Angeles, CA 90094-2536

USA

__________________________________________________

Cardholder Name

__________________________________________________

Company

__________________________________________________

Payment For (

)

Customer Name

*Please attach a detailed list if the payment is for multiple customers.

________________________

Billing Address

________________________

Phone

________________________

E-mail

_____________

Invoice Number

_____________

Amount

________________________

Credit Card Number

_____________

Expiration Date

__________________________________________________

Signature

Cardmember agrees to pay total in accordance

with agreement governing use of such card.

Please Note: chargebacks and declined transactions may be subject to an additional handling fee. Questions

regarding credit card payments can be sent to .

Credit Card Payment Form