CREDIT CARD PAYMENT FORM

The 32nd Conference of the
Middle European Cooperation in Statistical Physics
16-18 April 2007, Lądek Zdrój, Poland
CREDIT CARD PAYMENT FORM
Please complete all fields in block letters and fax this form to:
The 32nd Conference of the Middle European Cooperation in Statistical Physics
Fax: +48 71 344 1029
…………………………………………………………………………………………………..
Participant’s First Name and Surname
…………………………………………………………………………………………………..
The Institution
NB 1 – All payments by credit card must be increased by 3% with respect to the announced fees!!!
NB 2 – Participants sharing double room pay 250 + 7.5 (3%) = 257.5€.
NB 3 – Participants deciding to stay in a single room should pay 300 + 9 (3%) = 309€
NB 4 – Participants with accompanying person should increase their payment by 200 + 6 (3%) = 206€.
I authorize the organizers of the 32nd Conference of the Middle European
Cooperation in Statistical Physics to deduct from my credit card the total payment of
………… €.
Credit Card Type:
□ VISA
□ MasterCard
□ Diners Club
□ JCB
Cardholder’s name (as it appears on the card): .................................................................
Card number: ..............................................................................................................
Expiration date: ............................................................................................................
Cardholder’s signature and date: ................................................................................
In accordance of Polish Law “O ochronie danych osobowych” (Personal Data
Protection Act) we hereby declare that any personal information in our possession
will be used exclusively for the purpose of the 32nd Conference of the Middle
European Cooperation in Statistical Physics and will be removed afterwards.