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Credit Card Payment Authorization Template 3

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Credit Card Payment Authorization Template 3
Credit Card Payment Authorization Template 3
GUARANT International spol. s r.o., Opletalova 22, 110 00 Praha 1, Czech Republic
www.guarant.cz , Tel.: +420 284 001 444, Fax: +420 284 001 448,
[email protected]
FIA 2009 (CEFNet 2009)
Participant´s Name and
Surname:
Participant´s Address:
Participants´s Contact: ________________610-356-2363 ___________
Date:
CREDIT CARD PAYMENT AUTHORIZATION
I hereby authorize GUARANT International spol. s r.o. (Opletalova 22, 110 00 Prague 1,
Czech Republic, Comercial Registration number: 4524 5401) to charge my credit card for the
following payment:
Payment description – please specify the name of the event for which you pay (FIA
2009 or CEFNet 2009 or for both events):
TOTAL AMOUNT TO BE CHARGED:
According to the Czech law, credit cards will be charged in local currency – Czech crowns (CZK). The Guarant´s
Secretariat will use the exchange rate of the Czech National Bank on the date of payment.
Credit Card Details:
Credit card type: _________________________________
Credit card
number:
_________________________________
Expiry date: _______
CVC code
1
: _______
Cardholder´s name _________________________________
Billing address
2
:
______________________
__________________________________
1
CVC2 (MasterCard / EuroCard) or CVV2 (Visa, Diners) code is printed on the reverse side of your credit card at
the signature panel, after the number of your credit card (last three digits).
2
Please, do not forget to fill in the billing address (American Express only).
Cardholder's signature
Credit Card Payment Authorization Template 3