Saibt Celusa Credit Card Payment Authority Form printable pdf download

Saibt Celusa Credit Card Payment Authority Form

SAIBT/CELUSA Credit Card Payment Authority Form

I, ___________________________, hereby authorise the South Australian

Institute of

Business and Technology (SAIBT) and the Centre for English Language in

the University of South Australia (CELUSA) to debit my credit card, as

outlined below.

Student Details

Student's Family Name

____________________________________

Student's Given Name/s

____________________________________

Student’s Date of Birth

____________________________________

Institution*

____________________________________

Study Program

____________________________________

Amount

____________________________________

* Please indicate if the student’s tuition payment is for SAIBT, CELUSA or

both SAIBT & CELUSA

Credit Card Details

All credit card payments will incur a 1.5% credit card payment surcharge

Visa / MasterCard

(Please circle one only)

* Amex/Diners/American Express not accepted.

Credit Card Number

____________________________________

Name on Card

____________________________________

Expiry Date

____________________________________

Printed Name

____________________________________

Signed

____________________________________

Dated

____________________________________

New students please return completed form by fax to SAIBT/CELUSA Admissions

Department on +61 8 8302 11 82

Continuing students please return completed form by fax to SAIBT/CELUSA Finance

Department on +61 8 8302 11 82

Saibt Celusa Credit Card Payment Authority Form