Fillable Printable Apply Credit Card Authorisation
Fillable Printable Apply Credit Card Authorisation
Apply Credit Card Authorisation
08/16 Page 1 of 1 F014
F014 Credit Card Authorisation
Applicant name:
Daytime phone number:
Application number:
Application type: (Tick which applies)
Birth Certificate Marriage Certificate
Death Certificate Single Status Certificate
Change of Name Certificate Family History Certificate
Relationship Registration Fax to Passport Office
Certificate
PAYMENT DETAILS (Fees for Products and Services at: www.bdm.nsw.gov.au)
From 1 July 2016 a surcharge applies to credit card payments at the rate of 1.4% for AMEX and
0.4% for Mastercard or Visa. *Cheques are payable to NSW Registry of Births Deaths & Marriages.
I hereby authorise the NSW Registry of Births Deaths & Marriages to charge the following credit card:
Total Amount
$
Please debit AMEX MasterCard Visa or enclosed is a cheque*/money order
Card number
Cardholder name Expiry
TO LODGE: Please post this form to:
GPO Box 30, Sydney NSW 2001
OR
Email a scanned copy to:
[email protected].gov.au
Signature of
cardholder
