payment by credit card at distance

PAYMENT BY CREDIT CARD AT DISTANCE
Please fill out this form (one per participant), sign it and fax it to Madame LE ROUX,
the agent comptable of the Ecole Centrale de Nantes.
FAX number:
33 2 40 37 25 10 (from outside FRANCE)
02 40 37 25 10 (from FRANCE)
Last Name……………………………................…............................................................................
First Name..........................………….................................................................................................
Organisation………………………………………………………………………………………….
Address......................……………………..................................................................………………
………...................……………………..............................................................................................
Phone...................................................……………………................................................................
E-mail .........……………………........................................................................................................
Personal address ……………………........………………………….................................................
.............................................................................................................. .............................................
I authorize the payment, with the credit card whose numbers are given below, of the
registration fees to IWNMNNF 2012, 17th International Workshop on Numerical Methods for
Non-Newtonian Flows to be held in Blois – France from March 25th to 28th 2012, for an
amount of:
……………………………………………………………………………………………………….
(The amont must be written out in full letters and in numbers)
- CREDIT CARD:
- VISA:
- EUROCARD:
- CARD emitted by a French BANK:
- MASTERCARD:
Non-French BANK:
- Credit Card Number: _ / _ / _ / _ / - _ / _ / _ / _ / - _ / _ /_ / _ / -_ /_ / _ / _ /
- Cardholder Name ....................................... - Expiration date: _ / _ /
Date: ......................................
Cardholder Signature