Information and Communications Technology Authority

85 North Sound Way

Alissta Towers

PO Box 2502 GT

Grand Cayman

                                                                                                                     Ph: 345 946 4282

                                                                                                                      Fax: 345 945 8284

CREDIT CARD AUTHORIZATION FORM

Please fill out the following information to allow authorization of a credit card transaction to the ICT Authority.

I  duly authorize the Authority to debit my credit

(please print)

card account as listed below.

REFERENCE:

(Radio license type & particulars; ie: call sign, vessel name)

VISA , Expiration date

MASTER CARD , Expiration date

AMOUNT AUTHORIZED US$

BILLING ADDRESS:

CONTACT NUMBERS: Tel: Fax:

                                E-mail:________________________  

Signature of Card holder:

Should you have any questions, please contact our office for assistance.