Authorized Credit Card Usage Form printable pdf download

Authorized Credit Card Usage Form

Criminal Justice Division

Private Investigators and Security Guards Program

1800 – 155 Carlton, Winnipeg, Manitoba, Canada R3C 3H8

T 204-945-2825 F 204-945-2217

Authorized Credit Card Usage Form

 Credit Card information should not be e-mailed. Mail or fax this form to the

Private Investigator and Security Guard program (address and fax above).

 We accept Visa or MasterCard.

I authorize the use of the following credit card for the sole purpose of payment of

licensing, registration, exam administration and/or licence replacement fees as required

under The Private Investigators and Security Guards Act and Regulation of Manitoba.

Type of Card: ____________________________________________________

Credit Card Number: ____________________ Expiry Date: _______________

Cardholder’s Name (

_____________________________

exactly as shown on card):

Cardholder’s Phone Number: (___) ___________________________________

I authorize the following amount to be applied against this credit card:

$___________

Signature of Cardholder: ___________________ Date Signed: ____________

Authorized Credit Card Usage Form