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: email@example.com 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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