Credit Card Payment Form

Please fax completed form to the Qld Branch Secretariat on +61 7 3226 2899

Event Name:

Attendee Name / Contact:

Organisation:

Email:

Phone Number:

Notes or Comment (if paying for more than one attendee please list names here):

Credit Card Details
Payment authorisation for the AIIA to charge the following card:

Payment Amount:
Card Type:
Name on Card:
Card Number:
Expiry Date:

Signed:

 

_______________________________________