VETERINARY BOARD OF
THE NORTHERN TERRITORY
GPO Box 3000, Darwin NT 0801
Tel: (08) 89992028 – Fax: (08) 89992089
AUTHORISATION FOR PAYMENT OF ANNUAL
REGISTRATION FEES BY CREDIT CARD
Date:
_____/_____/_____
Type of Credit Card:
Please note we can only
accept the card types listed
Visa [
Credit Card Number:
__ __ __ __
Card Expiry Date:
__ __/__ __
Name of Card Holder:
____________________________________
Name of Veterinarian:
(if not the card holder)
____________________________________
Amount to be deducted:
$______
]
OR
Mastercard [
]
listed
__ __ __ __
__ __ __ __
__ __ __ __
Prescribed Annual Fee:
PRIMARY REGISTRATION
$172.00 (AUD)
(There is no prescribed fee for Secondary Registration)
Purchase Details:
Fee for Registration to practise
as a veterinarian in the Northern Territory - 2016
GST Code = NOO
Authorised to pay:
-----------------------------------Signature of Card Holder
[RTM use only: Code 922BPN09D134514]