COSIRES2010 Credit Card Payment Form - COSIRES

COSIRES2010 Credit Card Payment Form
Payment of COSIRES2010 conference fee for: ________________________
________________________________________________________________
I authorize the Jagiellonian University to charge the amount
of __________ PLN (max 5000 PLN) to the following credit card:
□ MasterCard
□ Visa
Card number: __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __
CVV2 (Visa), CVC2(MasterCard code): __ __ __
Expiration date: _______________ / _______________ (month/year)
Name as it appears on Credit Card:__________________________________
Billing address of Card: ___________________________________________
________________________________________________________________
Date: __________________________
Signature (not valid without signature) ________________________________
Please fax this form to +48 12 633 70 86,
or send a scan of the form to the conference e-mail: [email protected],
or send it by regular mail to:
COSIRES2010
Dorota Swierz
Institute of Physics
Reymonta 4
30-059 Kraków, Poland