ECC’09  
23-26 August 2009, Budapest, Hungary

CREDIT CARD FORM

After filling in and printing out this form, please send it
to the ECC’09 Local Secretariat

Eva Thiry, SCOPE Meetings Ltd.
H-1111 Budapest, Kende u. 13-17., Hungary; fax: +361 386 9378

I authorise the ECC’09 Local Secretariat (Scope Meetings Ltd.) to charge
the amount of EUR ………… to my credit card listed below.

Personal data  

Surname/Family name ……………………………………… First name …………………………………	

Phone (incl. country code) ……………………………………………………………………………………	

E-mail 	…………………………………………………………………………………………………………..

Credit card data

  EuroCard/MasterCard                              Visa

Card number 	 ………………………………………………….
Expiration date (mm/yy) …………………	
CVV code ………………………………	
(Last 3 digits of the security code on the back side of the card.)

Cardholder's name ………………………………………………………………………………………….	

Cardholder's address 	……………………………………………………………………………………….

Date: …………………………….……       Cardholder’s signature: ………………………………………