Canreach Immigration Consulting Inc.

7895 Tranmere Drive, Suite No. 205

Mississauga, ON L5S 1V9
Ph: (905) 696- 7434
Fax: (905) 696- 7436

Credit Card Payment Authorization Form

I, _______________________________________________hereby authorize Canreach
Immigration Consulting Inc. to charge my credit card for the amount of C$ 2,000.00
(Two Thousand Canadian Dollars) towards my Consulting Fee.
I am paying this fee on behalf of _____________________________________________
Credit Card Details:
Card Type: [ ] Visa [ ] Master Card
Card Number:
Expiry Date:
Validation Number:
(it is on back of the card three or four digits)
Name on Card:
Credit Card Billing Address:
Street________________________________________
City:________________________________________
Province/ State:_______________________________
Country:____________________________________
Postal Code:___________________________________
Phone Number:_________________________________

___________________________________
Cardholders Signature

________________________
Date