DIRECT-DEBIT-AUTHORISATION-FORM

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					                                       DIRECT DEBIT AUTHORISATION FORM

Bursar
Universiti Putra Malaysia
43400 Serdang
Selangor
MALAYSIA

AUTHORISATION TO DEBIT CREDIT CARD ACCOUNT

1.         I _______________ (Cardholder’s Name), NRIC No. (New)/Passport No (if applicable)____________authorise
           Universiti Putra Malaysia to debit my credit card account via Mail Order being payment of my registration fee
           for THE ASEAN UNIVERSITIES CONFERENCE ON PHYSICAL EDUCATION AND SPORT SCIENCE 2012 (AUCPESS
           2012) for (MYR / USD ) __________.

2.          Type of card:
          Visa Card
          Master Card
          American Express Card


3.         Account Number


4.         Card Expiry Date


      m         m         y        y

5.         Mobile phone:-______________ 6. Office / House :__________ 7. Fax no:____________

8.         Email Address: __________________________

9          I agree that I am personally liable for the payment of my registration fee for theASEAN UNIVERSITIES
           CONFERENCE ON PHYSICAL EDUCATION AND SPORT SCIENCE 2012 (AUCPESS 2012), if the above transaction is
           not approved by the Credit Card Centre.

10.         Cardholder’s Signature:


           ______________________________
            Name:                                                               Date :

               o    Attention: Please print this form, email or fax it together with your registration form to Secretariat of
                    AUCPESS 2012 through aucpess2012@putra.upm.edu.my or fax number (603-89468552).

				
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