Credit Card Authorization Form2010415225346 by lindayy

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									Credit Card Authorization Form
2009 International Symposium on Bioelectronics and Bioinformatics
9-11 December, 2009, Melbourne, Australia

Complete with block letters and fax to:

Ms. Vilma Athanasiadis
School of Electrical & Computer Engineering, RMIT University
GPO Box 2476V, Melbourne, VIC 3001, Australia.
Tel: +61 3 9925 1013 Fax: +61 3 99253242 E-mail: secretariat@isbb2009.wmah.org


Participant Information
 Organisation                                                    Title

                          First Name                             Surname
 Contact details

 Address                                                         Suburb/City


 State                    Postcode                               Country


 Phone                                 Fax                       Mobile


 Email



Registration Fee
                                 Before 15 Oct, 2009                       After 15 Oct, 2009
Student registration             A$250                                     A$300
IEEE or SMBE member              A$450                                     A$550
Non IEEE/SMBE member             A$500                                     A$600
Additional dinner order          A$75                                      A$75
Single day registration          A$200                                     A$300

Total registration               ____


Note: Approximately, AUD 1 = USD 0.76 = EURO 0.56 = JPY 75.73 = CNY 5.25
      For exact exchange rate, please visit http://www.oanda.com/convert/classic.


Credit Card Details

Name of card holder:
Card type:                     Visa            Master Card                 American Express

Card number:
Three digit card security code (last 3 digits of the number on back of the card):
Expiry date:

Signature of
card holder:                                                    Date:




I,                , undersigned authorize RMIT University, to debit the above total
order sum to my card as a payment of my ISBB2009 registration fee.

								
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