ONLINE PAYMENT SUBSCRIPTION FORM

Note that giving false information is an offence and is liable for prosecution or fine or both

Your Names as they appear in Card
Student/Pupil's Name & Reg Number
Specify Card Type	AMEX VISA SENATOR GOLD MASTER DISCOVERY
Specify Card Type if not in list above
Card Number
Expiry Date
Autho Code/ CVV/CSV No.
Amount to be Debited
Contact Telephone Number
Postal Address
Send a document of proof
Special Notes
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