After filling in and printing out this form, please send it to the
ICHST 2009 Secretariat
by fax or via mail:

Mariann Kindl , c/o ICHST 2009 Secretariat, SCOPE Ltd.
Kende u. 13-17., H-1111 Budapest, Hungary, fax: +361 386 9378

I authorise the SCOPE Meetings Ltd. (ICHST09 Secretariat) to charge
the amount of EUR …………………………..  (registration fee) to my credit card listed below.

Personal Data (Please print or type)

 Surname/Last Name	First Name	Middle Initial

 Fax (include country code)

 E-mail

Credit Card Data

                                EuroCard/MasterCard         	          Visa

Card number 	 Expiration date 	

CVV code 	
(Last 3 digits of the security code on the back side of the card)

Cardholder's name 	

Billing address 	

Date 	…..................................................          					Signature ............................................................