CREDIT CARD AUTHORISATION

I herewith authorise a once only payment of NZD$____________ to:

JAY SHADFORTH

IMMIGRATION LAW ADVOCATE

PO BOX 76

KAIAPOI

NEW ZEALAND

Payment is to be made by way of credit card.

Credit Card: BankCard ____ MasterCard ____ Visa____

Name of Card Holder:______________________________________

Card Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiry Date: _______________________________________

Signature of Card Holder:

_______________________________________

Date: ___ _______ ______ (Day / Month / Year)