Date:
Merchant address: Ústav makromolekulární chemie AV ČR, Heyrovského nám. 1888/2, 162 06 Praha 6, Czech Republic
Name of authorised merchant: Marie Rodová
Description of services ordered: Symposium fee and services for
Price of services:Registration fee:
Excursion:
Total price and currency (always in CZK): CZK
Name and surname of the cardholder:
Address:
Telephone, fax:
Card number: . . . . . . . . . . . . . . . .
Card validity till: Month: Year:
Last three digits printed on the signature panel:
EUROCARD-MASTERCARD/ CVC2 - Card Verification code 2:
VISA/ CVV2 - Card Verification value 2:
Description of the services ordered (including amount and price/currency):
I wish to pay the ordered services with my credit card. All the information stated above is correct and true. The bank (ČSOB, a.s.) will under no circumstances take action or carry responsibility for any controversy that can arise between the merchant and the cardholder as a consequence of the payment using above mentioned credit card(s) for goods or services. The payment will be performed in Czech crowns.
Date of order:
Signature of the authorised cardholder:
