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CREDIT CARD PAYMENT AUTHORITY
 
To QUINN-healthcare, I authorise you until further notice in writing, to charge my credit card account, unspecified amount in respect of subscriptions for QUINN-healthcare membership as and when these become due, until the instruction is countermanded by my giving notice to QUINN-healthcare.

Please tick
 
 
Mastercard/Access
 
Visa
 
If you wish to pay by credit card for this year only please tick the box. This will end the mandate after the payment has been made.
 
 
You will be given one month's notice of any subscription increase.
Cardholder's name, forename,other initials and surname:
 
 
 
Please insert your appropriate credit card number:
                                       
 
Expiry Date:
  20
   
Cardholder's
Signature:		 Date:
 
QUINN-healthcare membership number.
                         

Your insurance is provided by Quinn Insurance Limited. Quinn Insurance Limited (trading as Quinn Healthcare) is regulated by the financial regulator.