Slayt 1 - apmas 2012

CREDIT CARD MAIL ORDER FORM
APMAS 2012 CONGRESS
April 26-29 2012
I hereby authorize
Albedo Turizm Tic. Ltd. Sti.,
Cumhuriyet Cad. Ata apt. No: 161 / 3 Harbiye Istanbul - Turkey
to charge the credit card which details given below;
2. International Advances in Applied Physics Material Science Congress
Participant
Name and Surname
: ...................................................................... ...................................
Payment
Today’s Date (dd/mm/yy)
: ...... / ...... / ...........
Card Holder’s Name
: ...................................................................... ............................................
Bank name
: ...................................................................... ............................................
Card Number
:
Card Type
:
Master
Visa
American Express
Expiration Date (dd/mm/yy) : ...... / ...... / ...........
CVV Number
: ......... (The last three digits of the number printed on the backside of the card)
Amount (In Figures)
: ......................................................................
Amount (In Words)
: ......................................................................
I hereby confirm that the above information are correct.
Signature
Name Surname
Cumhuriyet Cad. Ata apt. No: 161 / 3 Harbiye Istanbul - Turkey
T: +90 212 230 17 97 (pbx) F:+90 212 230 16 49 [email protected]