XVII International Congress of Linguists
CREDIT CARD MAIL ORDER

 

DO NOT SEND THIS FORM BY E-MAIL!


[  ] VISA     [  ] EUROCARD/MASTERCARD     [  ] JCB
(Sorry for Credit Card Mail Order American Express is not accepted)

Card Number: ..................................................................................

Card Validation Value Code: ....................................................
(the last three digits at the signature stripe on back side)

Date of Expiration: ........................................................

Amount of payment:
conference fee in EUR:
      participant:  ..........................
      accompanying pers.:  ..........................
      student:  ..........................
banquet in EUR:  ..........................
accommodation in student dormitory in EUR:  ..........................
 
Total in EUR ..........................

To be paid to the order of CONFORG, s.r.o. for XVII CIL

Full Name as appears on Credit Card: .................................................................................

 

Cardholder's Signature: ..........................................................................................

E-mail Address: .................................................................................................

Mail Order Credit Card Payments are processed in the rate valid in time of charge in Czech Crowns only.