Debit/credit Card Payment Form

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Debit/Credit Card Payment Form
E
Embassy of Israel Consular Department · 15a Old Court Place, London W8 4PL
t 020 7957 9500 · e consulate@london.mfa.gov.il · w london.mfa.gov.il
In order to pay by credit/debit card, please fill out your full name and complete the card holder information:
Full Name of Applicant: _________________________________________________________________
Applicant’s Date of Birth:
Day: ____ Month: ____ Year: ____
Credit Card Type (check one): we do not accept American Express and Dinner’s Club
Visa
MasterCard
Or if you are paying by Debit Card:
Visa
MasterCard
Maestro
Electron
Solo
Name of Card Holder (as written on card):
_______________________________________________________________
Cardholder’s Address: (For processing the card payment only. All materials requested will be sent to the
applicant address provided on the appropriate forms.)
__________________________________________________________________
__________________________________________________________________
Card Number:
Expiration Date: ___ / ____
Start Date: ___ / ____
CVV Number:
(The 3 digit number written on the back of your card
after the card number in the signature area of the
card)
Total Charges (Pounds): £____________
Cardholder’s Signature (authorisation for payment):
I hereby authorise the Embassy of Israel to charge my debit/credit card for the total of all services requested
on the attached application, including any fee adjustments in effect as of the date the application is
processed.
______________________________________________________________________
Signature of Authorised Cardholder

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