1243 Islington Avenue, Suite 501 Toronto, Ontario M8X 1Y9
P : 416 234 8800 | F : 416 234 8820 www.alliancept.org
Credit Card Authorization Form
Debit credit cards are not accepted.
Credit card type (check one): Visa MasterCard
I authorize the Canadian Alliance of Physiotherapy Regulators to charge the following amount to my credit card:
Amount: in Canadian funds
Credit card number:
Card validation code (3-digit number on the back of your card):
Expiration date (mm/yyyy):
Cardholder’s name (Print the full name that appears on your card):
Cardholder’s signature:
Cardholder’s address:
Candidate’s/Applicant’s name:
Candidate’s/Applicant’s PIN (if applicable):
Candidate’s/Applicant’s signature:
Reason for payment (type of fee):
Date (dd/mm/yyyy):
