Electronic Payment Form	
Please provide this form with your application. 
	
Card Details	
CARDHOLDER’S NAME		
MASTERCARD     ☐	VISA    ☐	
CARD NUMBER:	     	
	
EXPIRY DATE:	
	CVV:

Applicant’s details	
Name:	
	
Address:	
	
Email: 	
	
Phone number:	
	
Amount due	

TOTAL AMOUNT
	
$____________________
	
Authorisation

I authorise the Civil Registry, Supreme Court of the Northern Territory to charge my credit card for payment of the relevant fee.

Card Holder’s Signature
		
Date: ___/____/____

OFFICE USE ONLY	
File Reference:		Receipt no.		
Processed by:		Date Processed: