Budapest 2004 Credit Card Form

After filling in and printing out this form, please send it to the Budapest 2004 Local Secretariat
by fax or via (air) mail:

Budapest 2004 Local Secretariat, c/o Mariann Kindl, MTA SZTAKI
Kende u. 13-17, H-1111 Budapest, Hungary, fax: +361 386 9378

I authorise the Budapest 2004 Local Secretariat (MTA SZTAKI) to charge
the amount of ………………………………..
to my credit card listed below.

Personal Data

Surname/Last name 	

First name	

Phone 	

E-mail 	

Credit Card Data

   American Express            EuroCard/MasterCard            Visa

Card number 	 Expiration date 	

CVV code 	
(Last 3 digits of the security code on the back side of the card  or  in case of AmEx card the additional 4-digit on the front)

Cardholder's name 	

Billing address 	

Date 	          Signature