UNIVERSITY OF KWAZULU-NATAL

CREDIT CARD FORM

Authorization to Debit my Credit Card

I hereby authorize University of KwaZulu-Natal to debit my credit card as detailed below:

CREDIT

Cost centre: R855 5205

Name of delegate :

Amount:

CREDIT CARD DETAILS

Card Name: 

Card Number:

Expiry Date:

Last 3 digits on back of card:

Identity Book Number (SA citizens only): 

Card Holder's Name:

Straight or Budget (Number of months):

Contact Telephone Number:

Signature:

Date:

Please fax or post to John Hilton or Anne Gosling, University of KwaZulu-Natal, Howard College, Durban, 4041, South Africa. Tel: +27 31 2601308, Fax: +27 31 2602698 
e-mail: hilton@ukzn.ac.za; or gosling@ukzn.ac.za