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PLEASE NOTE: Use this form to fill in the required information and print it afterwards. You can not send any information via web, this is a fax template only.NAME OF REGISTERED PARTICIPANT | |
Name of Participant: | |
Affiliation: | |
CREDIT CARD INFORMATION (VISA and MasterCard/Eurocard ONLY) | |
VISA: | |
MasterCard: | |
EuroCard: | |
Name of Card holder: | |
Credit Card Number: | |
CVV: | |
Expiry Date: | |
Signature of Card holder: | ________________________________________ |
PRIVATE ADDRESS OF CREDIT CARD HOLDER | |
Street: | |
Zip Code: | |
City: | |
Country: | |
Phone: | |
Fax: | |
Email: |