ICANN will accept Visa, Mastercard (Maestro), AmericanExpress, and Discover credit card payments for invoices not exceeding US $20,000 for ICANN fees and contributions.

Please print and completely fill out the following form to ensure timely processing. Credit card and address information is confidential. The completed form should be faxed or mailed to ICANN at:

FAX: +1-310-823-8649 or

MAIL: Internet Corporation for Assigned Names and Numbers (ICANN)
4676 Admiralty Way, Suite 330
Marina del Rey, CA 90292-6601
USA

Cardholder Name	__________________________________________________
Company	__________________________________________________
Payment For (Customer Name)	__________________________________________________ *Please attach a detailed list if the payment is for multiple customers.
Billing Address	________________________ ________________________ ________________________
Phone	________________________
E-mail	________________________
Invoice Number	_____________
Amount	_____________
Credit Card Number	________________________
Expiration Date	_____________
Signature	__________________________________________________ Cardmember agrees to pay total in accordance with agreement governing use of such card.