British Embassy, Warsaw

CREDIT / DEBIT CARD – PAYMENT AUTHORISATION SLIP

If you are applying for an Emergency Travel Document (ETD) and/or other Consular Services, you can pay by debit or credit card using this form. The cards we accept are Visa and MasterCard credit and debit cards. We are unable to accept Maestro cards, American Express, JCB or Diners’ Club cards.

Please print this form, enter your personal information and credit/debit card details as instructed and enclose it with your application. A separate credit card authorisation slip should accompany each application. If the cardholder name is different to the applicant’s name, please attach a photocopy of the cardholder’s passport or other photo ID with signature.

Actual fees at the time of issuance may fluctuate due to exchange rate movements. We will calculate the correct fee on your behalf. Your signature on this form indicates acceptance of these terms and authorises us to charge the actual fee to your card. You will receive a receipt showing the actual fee when your ETD or other service(s) is returned to you.

Applicant’s Details

Name:

Date of Birth:

Email Address:

Daytime telephone number:

Mobile telephone number:

Services requested: □ Administering an oath

□ Witnessing a signature

□ Making a copy of a document

□ Receiving a notice of marriage

□ Certificate of no Impediment

□ Emergency Travel Document

□ Other Consular Services – Please specify:

Payment type: □ VISA □ MasterCard □ VISA Debit □ MasterCard Debit

Card Number:

Expiry Date: / CVV Code (3-digit security code on back of card):

Cardholder’s Name:

Cardholder’s Passport/ID Number:

Cardholder’s Address:

Cardholder’s Tel. No:

Cardholder’s Signature: Date:

For use by Consular Section only:

Processed on / / By:______________