Generic Payment Form
1
Generic Payment Form www.birchamuniversity.net [email protected] Fax: +34 918162761 Bircham International University - APPLICATION FOR PAYMENT KL$-09<OAGMemail,B _________________________________________________________________________________________ - FULL NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 8P_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _________________________________________________________________________________________ - PAYMENT INFORMATION: 1- %F - AMOUNT: _ _ _ _ _ _ _ _ _ _ _ _ E&P ( ) % US$ ( ) ?! Euros 2- 說明 - DESCRIPTION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ – - MODE OF PAYMENT: A- - Credit Card: #1;C2N ( ) VISA ( ) MASTERCARD ( ) ); - AMERICAN EXPRESS ;+.P _____________________________________ 4P __________ *;HP __________________________________________________________ B- - Other: ( ) (J=53 - Bank Check included. ( ) PAYPAL - Visit www.birchamuniversity.info ( ) ="@ – DEUTSCHE BANK - Av. Infante Don Luis 8, 28660 Madrid, Spain I2+.P DEUTESBBXXX IBAN ?!@+ (Euros): ES43 0019 0583 4340 1000 9474 IBAN !@+ (US$): ES61 0019 0583 4340 5204 2839 I2/7:P BIRCHAM INTERNATIONAL UNIVERSITY. I do hereby authorize this application with my signature. <'6$>2DN #P _______________ <P ____________________________________
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Transcript of Generic Payment Form
Gen
eric
Pay
men
t For
m
ww
w.b
irch
amun
iver
sity
.net
i
nfo@
birc
ham
.edu
F
ax: +
34 9
1816
2761
Birc
ham
Inte
rnat
iona
l Un
iver
sity
������ - APPLICATION FOR PAYMENTKL$-�09<� O�AGMemail,B����
_________________________________________________________________________________________
�� - FULL NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
��P_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 8�P_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_________________________________________________________________________________________
���� - PAYMENT INFORMATION:
1- %F - AMOUNT: _ _ _ _ _ _ _ _ _ _ _ _ E&P ( ) �% US$ ( ) ?! Euros
2- 說明 - DESCRIPTION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
��� – ������ - MODE OF PAYMENT:
A- ��� - Credit Card:�#������1����;�C2N
( ) VISA ( ) MASTERCARD ( ) �)�; - AMERICAN EXPRESS
��;+.P _____________________________________ �4P __________
*;�H�P __________________________________________________________
B- �� - Other:
( ) (J=�53 - Bank Check included.
( ) PAYPAL - Visit www.birchamuniversity.info
( ) =�"@ – DEUTSCHE BANK - Av. Infante Don Luis 8, 28660 Madrid, Spain I2+.P DEUTESBBXXX
IBAN ?!@+ (Euros): ES43 0019 0583 4340 1000 9474
IBAN �!@+ (US$): ES61 0019 0583 4340 5204 2839
I2/���7��:P
BIRCHAM INTERNATIONAL UNIVERSITY.
I do hereby authorize this application with my signature.����<�'6$>2D�N
#P _______________ <P ____________________________________
