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International Admissions Office

299 Doon Valley Drive Kitchener, ON



N2G 4M4
FAX: 519-748-3520




C re dit C a rd Au tho ri zati on For m
SCANNED COPIES OF THIS FORM WILL NOT BE ACCEPTED

Please fax completed form to the International Office at 519-748-3520


Applicant Information PLEASE PRINT CLEARLY


Student Name:
Student Number:
Email Address:
Program Selection:
Payment Information

Visa
Card Number:
Master Card
Amex



Card Holder Name:
Amount to be charged:
Signature:
Expiry Date (MM/YYYY):
Security Code:













Note: By signing this waiver, you agree that Conestoga is not responsible
for any charges other than the transaction specified on this form. Future
transactions will require the submission of another authorized form.