BICI-INDAM School 2005 CREDIT CARD AUTHORIZATION FORM

Please complete the following form and fax it to

			+39 0543 446599


First Name: ......................... Last Name: ............................


[ ] Visa     [ ] Mastercard

I authorise the amount of ...... Euros  to be charged to my credit card.

Credit Card Number: ...............................  Exp. date: ...........

Name as it appears on Card: ...............................................

Date: ....................  Signature: ....................................