GUARANT International spol. s r.o., Opletalova 22, 110 00 Praha 1, Czech Republic
www.guarant.cz , Tel.: +420 284 001 444, Fax: +420 284 001 448, cecs@guarant.cz
www.guarant.cz , Tel.: +420 284 001 444, Fax: +420 284 001 448, cecs@guarant.cz
| Participant´s Name and Surname: | __________________________________________ |
|---|---|
| Participant´s Address: | |
| Participants´s Contact: | __________________________________________ |
| Date: | ___________________ |
I hereby authorize GUARANT International spol. s r.o. (Opletalova 22, 110 00 Prague 1, Czech Republic, Comercial Registration number: 4524 5401) to charge my credit card for the following payment:
| TOTAL AMOUNT TO BE CHARGED: | _________________ |
|---|
According to the Czech law, credit cards will be charged in local currency – Czech crowns (CZK). The Congress Secretariat will use the exchange rate of the Czech National Bank on the date of payment.
| Credit card type: | _________________________________ |
|---|---|
| Credit card number: | _________________________________ |
| Expiry date: | _______ |
| CVC code1: | _______ |
| Cardholder´s name | _________________________________ |
| Billing address2: | ________________________________________________________ |
1 CVC2 (MasterCard / EuroCard) or CVV2 (Visa, Diners) code is printed
on the reverse side of your credit card at the signature panel,
after the number of your credit card (last three digits).
2 Please, do not forget to fill in the billing address (American Express only).
_____________________________________
Cardholder's signature