Australian Embassy
Ireland
Embassy address: 7th Floor, Fitzwilton House, Wilton Terrace, Dublin 2 - Telephone: (353 - 1) 664 5300 - Fax: (353 1) 678 5185
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Credit Card Authorisation Slip
NOTE: Only Mastercard or Visa Cards can be debited without the cardholder being present.
FEES CHANGE ON A MONTHLY BASIS. You will be charged the fee current at the time of lodgement.
Registered Post fee will be automatically included unless otherwise indicated.
Please charge my Mastercard/Visa Account No:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Security Code (last three digits on reverse of card):
__ __ __
Expiry __ __ /__ __ Amount: € ___________
Cardholders Name: ____________________________
Cardholders Signature: _________________________
I agree to pay for the goods and/or services indicated and
agree to perform the obligations set forth in my agreement
with the card issuer.