PAYMENT BY CREDIT CARD

2nd Floor North, Chancery Exchange, 10 Furnival Street, London EC4A 1AB Tel: +44 (0)20 7245 6833 Fax: +44 (0)20 7245 6755 Payment of certification fees can now be accepted by VISA/Mastercard/American Express/Switch. If you would like to take advantage of this facility please complete and return this slip together with a copy of your invoice to the address above or email it to us at irca@irca.org PLEASE PRINT ALL DETAILS IN BLOCK CAPITALS If you fax this form to us, please do not mail/email it to us as well or your card may be charged twice. Please charge my certification fee to my VISA/Mastercard/American Express/Switch card as follows: Certification Number: Invoice number: Amount (Pounds sterling) ___________________ Card Number:

Expiry Date: ____/____ Cardholder Name (as shown on card): _____________________________________ Card security number (last 3 digits) _________ If you hold an American Express card, please provide the 4 digits security number On the front of the card____ If paying with a Switch card please write here the ISSUE NO: _ _ Signature: ___________________________ Date: __________________________
The Chartered Quality Institute, 2nd Floor North, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB Tel: 044 (0)20 7245 6722 Web: www.theCQI.org Incorporated by Royal Charter and registered as a charity number 259678