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PAYMENT FORM FOR AMERICAN EXPRESS CARD
Personal information
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Name |
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Permanent address |
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City |
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State |
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ZIP Code |
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Telephone (home) |
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Telephone (business) |
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Fax |
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E-Mail |
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Financial information
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Total amount |
Bht |
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Credit card name |
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Credit card number |
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CVV number(3 digits at the back of the card): |
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Expiration date |
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Authorized signature |
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Required Documents
a. Completely filled up and signed payment form
b. A photocopy of both sides of the American express credit card, which will have to be self attested by the credit card holder authorizing the use of the credit card for this transaction.
Important Notes
1. Please fax both the documents mentioned above to +6653128427 or email to info@ircns.org
2. IRCNS staff will contact you via email within 24 hours to confirm your payment after verifying your credit card.
3. I understand that no refunds will be made.
Date: _____________________________
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