FEES08 CREDIT CARD FORM
fee08creditcard.doc
Cashiers Office, Finance Department, Private Bag X3, Rondebosch 7701, South Africa
1 October 2009
“OUR MISSION is to be an outstanding teaching and research university,
educating for life and addressing the challenges facing our society.”
Cashiers Office Tel: +27 21 650 2127 Fax: +27 21 650 5093
Online credit card payments can be made direct to the student’s fee account: URL: http://payonline.uct.ac.za
To avoid duplications, please fax the completed form only ONCE and retain fax confirmation for your records.
I authorise UCT to charge my credit card in payment of the student fees account as indicated below:
□Mastercard
□Diners Club
□Visa
□American Express
FOR OFFICIAL USE:
Credit Card Number
DATE RECEIVED
D D M M C C Y Y
CVS number (3 or 4 digits)
(see back of card)
Expiry Date
DATE PROCESSED
M M Y Y
D D M M C C Y Y
Budget Account?
If Budget, no of months
Identity number of Cardholder
BATCH NUMBER
Yes No
Amount
Signature of Cardholder
AUTHORISATION CODE
■
Student Number
NAME OF CARDHOLDER
REASON FOR REJECTION
Student Name
ADDRESS OF CARDHOLDER
Tel No. during office hours/
Cellphone No.
PROCESSED BY:
(Print Name & sign)
Email Address/Fax No.
Date faxed to UCT