You may key in the data and then print this page OR print this page and then fill it in by hand. Please ensure that you sign the form.

PAYABLE AMOUNT US $80 - Option 2 (PROFESSIONAL ASSESSMENT)

Salutation:	Select Mr Mrs Ms Dr
Last Name (Surname):
First Name:
Middle Initial (optional):
Email Address:
State:
Country:
Post Code:
PAYMENT DETAILS:	Credit Card   Bank Draft   Money Order
Credit card type:	Visa Card  Master Card   Bank Card Amex    Diners      Swift / Solo - Issuer Code
Credit Card Number:	- - -
Card Expiry Date:	/  (MM / YY)
Name as on C. Card:
	(Added Security - We check this to prevent fraudulent use of any credit card.)
	_______________________ _______________________
	Signature of Card Holder Date