WINTER 2005 CREDIT CARD FORM

Please, fill in, print out and send back this form to the
WINTER 2005 Conference Secretariat by fax or via (air) mail:

WINTER 2005 Conference Secretariat, c/o Viktor Richter, SCOPE Meetings Ltd.
Kende u. 13-17, H-1111 Budapest, Hungary; fax: +361 386 9378

I authorise the WINTER 2005 Conference Secretariat
(SCOPE Meetings Ltd.) to charge the amount of
HUF ….………………………………….
as exhibition fee to the credit card listed below.

Company data  (please write in block capitals)

Company name 	

Contact surname/Last name 	

Contact first name	

Phone (incl. country code)	

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