Credit Card InForm

 After filling in and printing out this form, please fax or mail to the address below.

 

 

Ms. Mariann Kindl
EACL2003 Conference Secretariat
MTA SZTAKI
H-1111 Budapest
Kende u. 13-17
Hungary

Fax: +361-386-9378

 

 Personal Data

 Family name Given name
 Phone E-mail

Credit Card Data

 Card number Expiry date
 Cardholder's name
Cardholder's address
 CVV code (last 3 digits of  the security code - see the  back side of your card or  on Amex Cards the  additional 4-digit code on  the front)
Billing address

 
I allow the EACL03 (account no. 10032000-01738588) to charge my credit card of the amount of  HUF .......................

 Date ...........................................................................  Signature  ................................................................................