Credit Card Type (check one): CGFNS does not accept American Express
Name of Cardholder (as it appears on card):
Cardholder Address: (For processing credit card payments only. All
materials requested will be sent to the applicant address
provided on the appropriate forms.)
Credit Card #:
Total Charges (see “Fee Schedule”):
Cardholder Signature (authorization for payment):
I hereby authorize a charge to my credit card for the total of all
services requested on the attached VisaScreen®: Visa
Credentials Assessment Program Application Form, including
any fee adjustments in effect as of the date the order is received.
(See explanation on other side.)
Signature of Authorized Cardholder
3600 Market Street, Suite 400, Philadelphia, Pennsylvania 19104-2651 U.S.A.
Phone: 215.222.8454 • Web: www.cgfns.org
Credit Card Payment Form:
To pay by credit card, please fill in your full name (as it appears on this application) and your CGFNS/ICHP Applicant ID Number (if known)
below. Complete the cardholder information requested on the other side. Detach this form only if payment is being made by a third party.
Name of Applicant:
CGFNS/ICHP Applicant Identification Number
Applicant’s Date of Birth:
*Explanation of Credit Card CVV2 Number:
( To be entered below)
Visa and MasterCard: This
number is printed on your
MasterCard & Visa cards in
the signature area of the card.
(It is the last 3 digits AFTER the
credit card number in the
signature area of the card).