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CREDIT CARD PAYMENT AUTHORISATION

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CREDIT CARD PAYMENT AUTHORISATION Powered By Docstoc
					                  CREDIT CARD PAYMENT AUTHORIZATION
            Sympozium 20th FREJKA’S DAYS, 21-22 June 2012, Hotel Santon, Brno,
                                    Czech Republic

I hereby authorize TA-SERVICE s.r.o. (Hlinky 48, 603 00 Brno, Czech Republic, Commercial
Registration number: CZ27668436) to charge my credit card for the following payment:


Participant’s Name and Surname:                              …………………………………………………

Participant’s Address:                                       …………………………………………………

Participant’s Contact:                                       …………………………………………………

Total amount to be charged:                                  ……………….,- CZK / ……………….,-EUR


According to the Czech law, credit card will be charged in local currency – Czech crown (CZK).
TA-SERVICE will use the exchange rate of the Czech National Bank on the date of payment.


Credit Card details:

Cardholder’s name:                      ………………………………………

Credit card type:                       ………………………………………
only VISA and EC/MC cards are accepted (sorry, we do not accept AMEX)


Credit card number:                     ………………………………………

Expiry date:                            ………………………………………

CVC:                                    ………………………………………
CVC (Card verification Code) is printed on the reverse side of your card (EC/MC, VISA) at the signature panel, last three digits.



Important note:
The copy of both sides of the credit card with cardholder’s signature must be attached to this form.




…………………………………………….
Cardholder´s Signature


                    Please, fax the filled and signed Authorization with copy of the credit card
                                     to fax number: 00420 543 211 134


                                    TA-SERVICE s.r.o., Hlinky 48, 603 00 Brno, Czech Republic
                      tel./fax: +420 543 211 134, e-mail: conference@ta-service.cz, web: www.ta-service.cz
                                           ID no.: 27668436, VAT ID no.: CZ27668436

				
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