Payment Form: fees payable for the recognition of a continuing education activity Provider name Primary contact name Title of the activity Recognition code (5-digit) Fees payable In the box below, please enter the amount payable for your application for recognition, as stated in the email sent to you by the Chambre de la sécurité financière. Amount payable (taxes included) $ Please enter valid amount. Basic fees are mandatory and are non-refundable. Billing I authorize the Chambre de la sécurité financière to charge the amount of 0 $ to the credit card listed below. This represents the amount payable (basic fees and, if applicable, additional fees and taxes.) First Name Last Name Company Name Email Address City Province - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward Island QuébecSaskatchewanYukon Postal code Telephone I understand that checking this box constitutes a signature having legal force. Terms and Conditions for the purchase of online services Leave this field blank Federal Tax: 875755423 RT / Provincial Tax: 1022122980 Payment secured by Moneris The CSF will not have access to the payment data entered through the online payment form.