Credit Card InForm

IMS Workshop
6-8 April 2003, Budapest

 After filling in and printing out this form, please fax or mail to the address below.

 

 

Ms. Eva Thiry
IMS 2003 Workshop Secretariat
MTA SZTAKI
H-1111 Budapest
Kende u. 13-17
Hungary

Fax: +361-386-9378

 

 Personal Data

 Family name Given name
 Phone E-mail

Credit Card Data

Card number Expiry date
Cardholder's name
Cardholder's address
Last 3 digits at the back of the card


 

Date ...........................................................................  Signature  ................................................................................