Service Request Form Page 3
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32283 St. Laurent Blvd., Suite 100
ADDRESS
Ottawa, ON CANADA K1G 5A2
Tel: 613-520-2240
CONTACT
Fax: 613-248-5234
MCC.CA
Email: service@mcc.ca
CREDIT CARD AUTHORIZATION FORM
Complete in BLACK INK only and submit this form for all credit card payments
that cannot be submitted through your physiciansapply.ca account.
Please note: Credit card payments will be processed in Canadian funds only.
Surname
Given Names
MCC Candidate Code
(if available)
Reason for payment - Fee related to:
F Evaluating Examination (MCCEE)
F Qualifying Examination Part I (MCCQEI)
F Qualifying Examination Part II (MCCQEII)
F National Assessment Collaboration (NAC) examination
F Clinical skills component in family medicine
F Other Fee (please explain): __________________________________________________________
* As a cardholder, I authorize the Medical Council of Canada
to charge my card in the amount of
$
Credit Card Type:
VISA
MasterCard
VISA or MasterCard acceptable ONLY
Credit Card Number:
Expiry
CVV
Date:
Number: *
___ ___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___
___ ___ ___
month / year
* The three-digit CVV number is printed on the signature panel on the back of the card
Cardholder must print and sign his/her name below:
*Name of cardholder:
(please print)
*Signature of cardholder:
*Address of cardholder:
(if different from
candidate’s address)
* Required
MCC | Credit Card Authorization | P3
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