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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)
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