Date:
Department:
Prepared by:
Email:
Phone:
10000-00000-2022 GST
10000-00000-2001 PST
Province: Postal Code:
Cardholder Name:
Street Address:
City:
Phone:
Primary: Alternate:
Payment Method: VISA
AMEX
Credit Card Holder Signature:
Credit Card Number:
Credit Card Expiry Date (mm/yy):
MASTERCARD
Return to Accounting Services, ASB B115 for processing
Total
AmountCredit FAST Account Description of Sale
Revised Nov 2016
Credit Card Processing Request
Payment Information
*
Credit card number not to be kept on file
I authorize the University of Victoria to charge the above amount to my credit card provided above. I certify that I am the
authorized cardholder and signer for the credit card information provided.
*For accounts receivable, note the GR# in the description field and code to 10000-0000-1130
0.00
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