IDLOAC GENERIC PAYMENT FORM

Fill out & Sign this application, and then send it by email attachment with the required documents.

APPLICANT PERSONAL DATA

FULL NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
International Distance Learning Online

Full shipping address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

info@idloac.org

E-mail: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Contact Phone Numbers: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Accreditation Commission

PAYMENT INFORMATION:
1- AMOUNT: _ _ _ _ _ _ _ INR | USD | EUROS

2- DESCRIPTION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
http://www.idloac.org

MODE OF PAYMENT - Circle one option.

B- Bank Transfer: ICICI BANK (C.G ROAD, Branch, Ahmedabad, Gujarat, INDIA)
IFSC Code: ICIC0001367 Account no: 136701000460
Account Name: CIHF (Not for Profit Parent registered Body)

B- Credit Card: ( ) VISA ( ) MASTER CARD ( ) AMERICAN EXPRESS

Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration Date: _ _ _ _ _ _ _ _ _ _ _ _

Card holder full name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

C- Other: ( ) Check included with this application ( ) Payment already conducted online.
IDLOAC Payment Form

I do authorize the payment of the selected items with my signature.

No refunds or cancellations accepted once the items have been ordered.

Today’s date: Signature: