InCert - Visa / MasterCard, Credit Card Payment Form

VUE Testing Centre - Manchester

Postal Credit Card Payment Form

YOUR DETAILS
Title
First Names *
Surname *
Date of Birth *
Address *
Post Code *
Daytime Tel No *
Evening Tel No
Email Address *
PAYMENT METHOD
Card Type *
Card No *
Valid From (mm/yy) *	Valid To (mm/yy) *
AMOUNT IN POUNDS *
DECLARATION I confirm that the information given on this application is true and I authorise you to make any credit reference or other enquiries in accordance with your normal procedures in connection with this application. I confirm that I am at least 19 years old and that I am the holder of the above valid credit card I understand that if this application is successful InCert will collect the amount shown immediately from the credit card above. I understand that in the event of a credit card payment not being authorised by the card issuer the outstanding balance becomes immediately payable in full and that any training is suspended until the balance is paid. I understand that if this credit application is successful I will be sent confirmation and will be booked onto courses from that date.
Name Signature Date