Credit card faxform
Innovative Mass Storage Technologies 2007
Enschede, June 18, 19, 20
Please complete this faxform and fax it to
+31 53 4894442
Info on Payments:
University of Twente
CongresAssociatie Twente B.V.
P.O. Box 217
7500 AE Enschede
The Netherlands
Tel: + 31 53 4894444
Fax: + 31 53 4894442
E-mail: cat@cat.utwente.nl
In order to guarantee your registration, please fax this form and, for early registration, make sure
you have paid your total fee before 1st of May 2007.
--------------------------------------------------------------------------------------------------------------------------------Hereby I grant the CongresAssociatie Twente B.V to deduct the amount of
€ ………………
in characters…………………………………………………………… Euros
From my Visa / MasterCard / American Express* Credit card
(* please strike out what is not applicable)
Cardnumber
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Expiration date (dd/mm/yyyy) ………………………………………………………………………….
Card Validation Code (CVC)
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Name of Cardholder
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Adress of Cardholder
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Postal Code
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City
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Country
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--------------------------------------------------------------------------------------------------------------------------------Name of registrant
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E-mail address of registrant …………………………………………………………………………
Organization of registrant
Date:
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Signature (Cardholder):