– payment by credit card –

FEE
– payment by credit card –
Participant’s Name:
Amount due (in euros):
Type of Credit Card:
CB
MasterCard
Visa
EuroCard
Card Number:
Cryptogramme visuel pour les cartes françaises :
(les trois derniers chiffres figurant sur le panonceau signature au verso de la carte)
Expiration Date:
Cardholder’s Name:
Cardholder’s Telephone:
Cardholder’s Fax:
Cardholder’s Private Address (city, country):
Date:
Send this form by post to:
PHOTODET 2012 - Mme Valérie Brouillard
Laboratoire de l’Accélérateur Linéaire
Bât. 200 - BP 34 - 91898 ORSAY CEDEX - FRANCE
Cardholder’s signature: