Hong Kong Junior Chamber Visa Card



Junior Chamber International Hong Kong Visa Card

JCI Activity Fee Payment Authorization Form

I hereby authorize Shanghai Commercial Bank Ltd. to debit my Junior Chamber International Hong Kong Visa Card account for payment of the following activity:

|Membership Registered Name |： |____________________________________________ |

|Chapter |： |____________________________________________ |

|NOM Position (if any) |： |____________________________________________ |

|LOM Position (if any) |： |____________________________________________ |

| | | |

|Cardholder Name |： |____________________________________________ |

|HKJC Visa Card No. |： | |

| |： |_____________________ |

|The last 3 digit on the back side | | |

| |: | |

|Activity Details/Membership Due/ | | |

|Donation | | |

|Fee for the above activity |： |HK$________________________________________ |

|Contact Telephone No. |： |____________________________________________ |

|Cardholder Signature | | |

|(The signature must be the same as that |： |____________________________________________ |

|appeared on the card) | | |

|Date |： |____________________________________________ |

Terms & Conditions:

1. This payment option for fee of participating activity mentioned above which are affiliated with Junior Chamber International Hong Kong is provided for Junior Chamber International Hong Kong Visa Card cardholders only.

2. This authorization should come to effect upon approval by Shanghai Commercial Bank Ltd.

| |

|Please complete and submit this form to your chapter Honorary Treasurer |

|For Bank Use Only: Merchant No.: 08 11931 7 |

|Auth. Code: ______________ |Date: _____________________ |Processed by : __________________ |

|Authorization Centre: |Fax line: 2818-5905 |Enquiry: 2818-6328 |

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