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