Credit Card Payment Authorisation Form

Credit Card Payment Authorisation Form

PLEASE COMPLETE THE FOLLOWING SECTIONS
Section 1 - Student Personal Details
Student ID*
Gender*
Student Complete Name*

First NameMiddle NameLast Name
Current Campus*
Current Course*
Email address*
example@example.com
Mobile Number*
Agent's Company Name (if applicable)
If you have an agent, please mention their company name in this field
Section 2: Credit/Debit Card Details
Card Type*

VisaMastercardAMEX
Card Number*
Full Card Number (VISA/Master/AMEX Only)
Expiry Month*
Card Expiry Month
Expiry Year*
Card Expiry Year
CCV Code*
Behind the Card of Visa/Master or at front AMEX
Amount to Pay ($AUD)*
Please mention the amount in number only
Section 3 - Student Declaration
I (your full name),*
PRINT FULL NAME
I, (your name mentioned as above) hereby give permission to Auscanus Insitute of Australia (AIA) to debit my credit or debit card as per the card details provided in above Section 2. I also understand that the amount mentioned in Section 2 will inncur a surcharge of 2.5% for Visa or Mastercard and 3.5% for AMEX cardholders for the abovementioned student.
Student Signature*

Clear
Date*

DayMonthYear
Please verify that you are human*
Should be Empty:

Section 1 - Student Personal Details