Credit Card Authorisation
About this form You have advised the Department of Jobs and Small Business that you would like to pay the charge
imposed for the processing of your Freedom of Information (FOI) request by credit card. This form
collects the details required from you in order to process that payment by credit card. Please
ensure all fields have been filled in correctly.
Part 1: Applicant Details
Name:
Contact number:
Part 2: Credit Card Details
I authorise the Department of Jobs and Small Business to debit my credit card in the amount of:
(please specify amount in the space provided)
Cardholder’s Name (please print name in capital letters):
Credit Card Number:
Credit Card Type:
(Diners Card not accepted)
Credit Card
CCV Number
Expiry Date:
Card Holders Signature:
Date:
Privacy Statement
The personal information collected on this form is collected by the Department of Jobs and Small
Business (the department) for the purpose of administering payment of the charge imposed for
processing your FOI request. The personal information collected will only be used for this purpose
and any related purposes. The personal information collected will not be disclosed unless
authorised or required by law. Further information on how you may access or seek correction of
your personal information held by the department or how you may make a complaint is available in
the department’
s Privacy Policy.