CREDIT CARD AUTHORIZATION FORM7 by benbenzhou

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									                                                             March 21 - 24, 2010
                                                Jordan University of Science & Technology




                     CREDIT CARD AUTHORIZATION FORM
 I, hereby, authorize Jordan University of Science & Technology to charge an amount* of United States
 $ ____________________________ to my credit card (details mentioned below) for the INREC’10 registration &
 desired tutorial fees.
 NAM E OF CREDIT CARD HOLDER (PRINT below exactly as it shows on the front of card ):

 _________________________________________________________, DOB (mm/dd/yy): _____________________

 BILLING ADDRESS : ___________________________________________________________________________

 ______________________________________________________________________________________________

 M AILING/RESIDENCE ADDRESS (if different from billing address): ____________________________________

 ______________________________________________________________________________________________


 AF FILIATION: __________________________________________________________

 IEEE, ANS, or CNS M ember? (yes, fill in member number here______________________________), No:______

 CREDIT CARD TYP E: (VISA/M C ) __________________________________ EXP IRY DATE : _____/_______

 CREDIT CARD NUM BER ** : ______________ - ______________ - ______________ - ______________

 CVC2/CVV2 (3-digit number taken off of the back of your card): _____________

 SIGNATURE: _____________________________________________________________________

 TEL. NO.(while in Jordan) (if available) ______________________ , Desired HOTEL: _____________________

 Desired HOTEL Ph. No.: _______________________________________

 HOM E TEL. NO. (______) ____________________

 F AX NO. (________) ___________________________ DATE: _______________________________________

 IF AUTHOR: ABSTRACT ID #: {#INREC10} ________________

 E-M AIL ADDRESS: ___________________________________________

* If you are using MasterCard, then MasterCard International requires your supplementing a photocopy of your
MasterCard credit card of both sides of the card.
** To preserve the security of your credit card information, NEVER send this form via email. Always send by fax to the
INREC’10 fax number provided through the main registration form.

								
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