Sensitive NSW POLICE FORCE

Credit Card Payment Form Subpoena Processing – Conduct Money

Version: July 2018 Sensitive Page 1 of 1

This form is to be used for making payment by Credit Card for a subpoena processing A valid subpoena must be issued to the New South Wales Commissioner of Police and

accompanied by payment of conduct money.

SUBPOENA FILED BY

First & Other Name/s Last Name

Business Name (If applicable) ABN

Address

Contact Phone Number Email Address

SUBPOENA DETAILS

Court Name Court File Number

Proceedings Name NSW Police Force Subpoena Number (if known)

CREDIT CARD AUTHORITY

The NSW Police Force is collecting this information so that we can process the fee ‘conduct money’ for subpoena processing. We will process the request using a secure interface with Westpac Banking Corporation, and will not disclose the information

to any other third party.

Please debit my credit card to the amount of: $95.80 (AUD)

e

V

Date Card Number

Expiry Date

Card Holder Signature Date

details of the same provided above and you acknowledge that it is an offence to provide false or misleading information.

INFOLINK USE ONLY

Application Reference Number Application Date Receipt Number

Successful Payment Unsuccessful Payment Date

Note: By signing as the cardholder, you confirm that you are the owner or authorised signatory of the Credit Card and

Card Holder Name

Card Type VISA MASTERCARD