TOC - UK Border Agency

PAYMENT DETAILS:TOCPlease complete this page in block capitals and black ink after first reading the payment guidance.1Contact address in the UK for correspondencePostcode2Contact name in the UK if different from that of the applicant3Applicant’s full name4Date of birthDay Month YearPAYMENT DETAILS5 Amount - please tick the amount you are payingSingle applicant -no dependants£107Main applicant andtwo dependants£321Main applicant andone dependant £214Main applicant andthree dependants £4286How are you paying? Please tick a box.PostalorderChequeDebit orcredit cardBanker’sdraftIf more than 3 dependants are applying with you, please state the number in the space below and enter the correct amountspecified in the payment guidance in the appropriate box.Main applicant and .............. dependants £ - postal7Paying by cheque - please give cheque details belowCheque numberAccount numberSort codePaying by card - please complete 8-12 below8Which card are you using for payment?Please tick a box.Visa /ElectronMasterCard/ AmexDelta Maestro /Solo9Name oncard10Cardnumber1112Card detailsCardholder’ssignatureValid fromExpiry dateCard security number - CVV(3 digit number or4 digit number forAmex)DateIssue No.(whereavailable)TOC Application Form (Version 10/2014) - Page 4 of 22