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PAYMENT AUTHORIZATION FORM ADDITIONAL TEST REPORT FORMS TRFs Section 1 Postage Less Than 30 Days from Test Date up to 5 test report forms Canada Nation-wide 3. 00 per TRF x of TRFs being mailed United States of America 5. 00 per TRF x Total 23. 00 20. 00 TRF 3. 00 postage per copy x There is a mandatory courier charge of 75. 00 to mail TRFs to overseas destinations. Section 3 Courier Charges Add 20. 00 per TRF if it is more than 30 days or over 5 TRFs if it is less than 30 days from your test date. If you prefer that your results be sent by courier please indicate below Unit Price per TRF s and include the applicable courier fees. Unit x TRF s Provincial within Ontario 20. 00 National within Canada 30. 00 45. 00 International Overseas 75. 00 Indicate which TRFs are to be sent via courier Institution Name Total Fees Section 1 Section 2 Section 3 TOTAL Attach Money Order or Certified Cheque made payable to Conestoga College to this form OR complete all information below. NOTE Declined credit card transactions will be assessed a Handling Fee of 20. 00 CREDIT CARD AUTHORIZATION Name Address Phone E-mail VISA MASTERCARD Expiry Date / Month / Year Card Number no spaces or dashes I hereby authorize CONESTOGA COLLEGE to charge Cdn* to my credit card. Signature of Card Holder Date Receipt For Office Use Only 10-Apr-14 Please email this form to additionaltrf conestogac*on*ca. 00 per TRF x of TRFs being mailed United States of America 5. 00 per TRF x Total 23. 00 20. 00 TRF 3. 00 postage per copy x There is a mandatory courier charge of 75. 00 to mail TRFs to overseas destinations. 00 postage per copy x There is a mandatory courier charge of 75. 00 to mail TRFs to overseas destinations. Section 3 Courier Charges Add 20. 00 per TRF if it is more than 30 days or over 5 TRFs if it is less than 30 days from your test date. Section 3 Courier Charges Add 20. 00 per TRF if it is more than 30 days or over 5 TRFs if it is less than 30 days from your test date. If you prefer that your results be sent by courier please indicate below Unit Price per TRF s and include the applicable courier fees. If you prefer that your results be sent by courier please indicate below Unit Price per TRF s and include the applicable courier fees. Unit x TRF s Provincial within Ontario 20. 00 National within Canada 30. 00 45. 00 International Overseas 75. Unit x TRF s Provincial within Ontario 20. 00 National within Canada 30. 00 45. 00 International Overseas 75. 00 Indicate which TRFs are to be sent via courier Institution Name Total Fees Section 1 Section 2 Section 3 TOTAL Attach Money Order or Certified Cheque made payable to Conestoga College to this form OR complete all information below. 00 Indicate which TRFs are to be sent via courier Institution Name Total Fees Section 1 Section 2 Section 3 TOTAL Attach Money Order or Certified Cheque made payable to Conestoga College to this form OR complete all information below. NOTE Declined credit card transactions will be assessed a Handling Fee of 20. 00 CREDIT CARD AUTHORIZATION Name Address Phone E-mail VISA MASTERCARD Expiry Date / Month / Year Card Number no spaces or dashes I hereby authorize CONESTOGA COLLEGE to charge Cdn* to my credit card.

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