UNIVERSITY OF KWAZULU-NATAL

CREDIT CARD FORM (Print out and post/fax)

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