ICALP and LICS
Turku, July 2004

Credit card authorisation

Please fill in this form, print it out, add the signature and send the form by fax to:

	Congress Office, University of Turku
	Address: Lemminkäisenkatu 14-18 B, FIN-20520 Turku (tel. +358 2 333 6485)
	Fax +358 (0)2 333 5008

Name(s) of participant(s):	
     	

I hereby authorise the Congress Office, University of Turku to charge my credit card as follows:

	  Visa	  Eurocard		  Mastercard

Total  in EUR	
     	

Credit card number	    	    	    	    	

Expiry date (mm/yy)	
     	

Name as it appears on the card	
     	

Card holder’s address	
     

Date _______________  	Signature ________________________________________