Credit Card Payment Form

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PLEASE PRINT ALL DETAILS CAREFULLY Credit Card Payment Form

To:

Accounts: Edith Cowan College

Mail:

Edith Cowan College ECU Joondalup Campus – Building 31 270 Joondalup Drive Joondalup 6027 Western Australia

Fax:

(+61 8) 6279 1111

Please tick the appropriate box: Cost

Tuition Fees (PATHWAY)

$

Tuition Fees (ELICOS)

$

Other Charges/Materials

$

OSHC

$ TOTAL AMOUNTS AND COPY INTO SPACE BELOW

$ ACN 064 377 993

First Name:

Family Name:

Card type: (circle one)

Note: we do not accept American Express or Diners Club cards

Charge my credit card with the amount:

$

Card number: Card Expiry:

/

CCV Number:

The credit card verification number (CCV) is a 3 or 4 digit code. For Visa and MasterCard, it is the last 3 digits found on the reverse of the card.

Name of Cardholder: Date:

Cardholder Signature:

/

/

Daytime Phone Number (include area code): Address of cardholder: Suburb:

Post code:

Checklist: Please ensure you have… 1. Signed 2. Dated 3. Checked the amount payable 4. Included your address and contact phone number

QBIFO007 H:\Forms\Credit Card Payment Form (Pathway).Doc

Last Updated: 31/08/2017 Page 1 of 1