The Belize Council for the Visually Impaired

Princess Margaret Drive

P.O. Box 525
Belize City
Phone: 501-223-2636
Email: bcvibze@gmail.com
PAYMENT PLAN

This agreement is made this ___ day of _________, 2016

For due consideration, the undersigned _____________________ for (procedure/surgery)
_____________________, promises to pay to the order of The Belize Council for the Visually
Impaired at Princess Margaret Drive , Belize City, Belize, Secondary Eye Care, the sum of
_______________.
Instalments of:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Has paid so far:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Thank you for choosing BCVI as your eye-care facility.

___________________
Customer Name (Print)
Contact No. __________________
WITNESS to the above signature,
____________________________
Administrative Officer

___________________
Signature of Customer