Credit Card Authorization Form

To: Caribbean College of Family Physicians

From:

Date:

Country:

Kindly debit my Credit Card as follows:

# of years:

Kindly state other/Date of meeting:

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This serves to authorize Caribbean College of Family Physicians to debit my credit card as follows:

Name:

Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone #:

Amount:

US$/J$

Bank:

Card Type:

Card Number:

Email credit card information to familydoctorsregional@gmail.com

(To facilitate card privacy, please provide the rest of the card number in an email or WhatsApp).

Year of expiration

Email expiration details to familydoctorsregional@gmail.com

Card CVC2 (Mastercard) or CVV2 (Visa) Number:

(Card Validation Code or Card Verification Value – Unique three digit number at back of card)

Special Instructions:

Please call the secretariat at 876-517-6636 for how to make payments via credit card

Signature: