INSTITUT PASTEUR

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					                                                Communicable and Infectious Diseases                                                        T. +32 2 373 31 50
                                                RABIES LABORATORY                                                                           F. +32 2 373 32 86
                                                National Reference Centre                                                                   rage@iph.fgov.be
                                                Rue Engelandstraat 642 | 1180 Brussels | Belgium                                            www.iph.fgov.be
                                                                                                              This document is available on the website


                                                                                   PAYMENT FORM

       All payments must be made in euro and free of bank charges.

        FOR PAYMENT BY BANK TRANSFER DIRECTLY TO OUR BANK
              Fortis, rue Montagne du Parc 3, 1000 Brussels, Belgium
              Bank account: 001-4131936-06
              IBAN: BE85 0014 1319 3606
              BIC: GEBABEBB
              Communication: invoice number and customer number, or if not known:
               For the serology test : the name of the owner and the name of the pet
               For the vaccines : the name of the doctor and the name of the patient

        FOR PAYMENT BY VISA CREDIT CARD (VISA ONLY)
              Please fill in and return this form to:
              Institute of Public Health Patrimony
              Mrs. H. De Meyer
              Rue Juliette Wytsmanstraat 14
              1050 Brussels
              Belgium
              Fax : 00 32 2 642 50 01
              E-mail : rage@iph.fgov.be



I, undersigned, authorize the Institute of Public Health Patrimony, to debit the sum of ........... euros to my
VISA credit card for the payment of invoice :

Reference number of the invoice : ..................................................................................
Customer number : .........................................................................................................
Dated : .............................................................................................................................

Credit card number :




CVC code (the last three numbers on the back of the card) : ............
Expiry date (mm/yyyy) : ...................................
Name and address of card holder :                        .............................................................................................................
                                                         .............................................................................................................
                                                         .............................................................................................................
                                                         .............................................................................................................


Date




COMMUNICABLE AND INFECTIOUS DISEASES                           HEAD OFFICE
Rue Engelandstraat 642 | 1180 Bruxssels | Belgium              Rue Juliette Wytsmanstraat 14 | 1050 Brussels | Belgium
T + 32 2 373 31 11 | F + 32 2 373 32 81                        T + 32 2 642 51 11 | F + 32 2 642 50 01
       Application date :                                              FORM 13/N/86 v1                                                                                   1/1

				
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posted:10/5/2012
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