CREDIT CARD AUTHORIZATION FORM
ACSWE CONFERENCE 2007
REGISTRATION PAYMENT
Credit Card Authorization Form 
I, ___________________________________________ , hereby authorize  
The University of the West Indies
to charge my credit card account in the amount not to exceed: $____________________ 
( ) VISA ( ) MasterCard ( ) American Express ( ) Discover 
Credit Card Number: _______________________________________________________ 
Expiration Date: _____ /______ VID Code: ____________ 
Credit Card Billing Address: 
Street: ____________________________________________________________________ 
City:________________________________________________ State: _____________ 
Zip Code: ___________ - _________ Country: _________________________ 
Telephone: ( ) _____- _________ 

__________________________                 ____/____/____
Cardholder's Signature                         Date dd    mm  yyyy