CQU Credit Card Authority

CQUniversity Credit Card Authority

For payment of IELTS Examinations only.

PAYMENT DETAILS:

Date: _____/_____/_____

Please debit my Credit Card: AUD $ __________________

Cardholder’s Name: _______________________________________

Cardholder’s Number: _______________________________________

Expiry Date: _____/_____

Credit Card Type: Mastercard o Bankcard o Visa o

Cardholder’s Signature: _______________________________________

Applicant Name: _______________________________________

I will be taking (please circle): General Training Module / Academic Module

Test Date: _____/_____/_____

CQUniversity Use Only

Receipt Number: __________________ Date:_____/_____/_____

PLEASE FAX OR SEND THIS FORM AS SOON AS POSSIBLE SO PAYMENT CAN BE PROCESSED TO:

Attn: IELTS Administrator

CQUniversity English Language Centre

Bruce Highway

North Rockhampton QLD 4702

Phone: +61 7 4930 9790

Fax: +61 7 4930 6321

e-mail: OR

Internet: www.language.cqu.edu.au

*Please ensure that the GST Form has been completed and submitted with the payment.