AUTHORISATION FOR PAYMENT BY CREDIT CARD
I hereby authorize that my Credit Card Account be debited in favour of The Macromolecular Society of SA (MSSA) with the amount as indicated hereunder in respect of my enrolment and registration fee for the 14th Annual UNESCO/IUPAC Workshop & Conference on Macromolecules & Materials that will be held in Stellenbosch, South Africa from 10 - 13 April 2017.
Name of card holder (Please print clearly):___________________________________
Number of Passport:____________________________________________________	
Credit card number:
																
Expiry date:
		/			
CVC number (last three digits of number on reverse side of the card):
			
Name of card (VISA or MASTER):_______________________________
Amount to be debited against card account:
Currency (£ Sterling / Euro / US $ / Rand ):  ___________________Total:______________
(Office use only:  Forex rate:___________; Project cost number:________________)	
Signature of card holder:_________________________Date:_______/_____/_____
NB!  If you are paying on behalf of a third party, please give the name and contact details of that person:
___________________________________________________________________	
Mail or fax this form together with your registration form to the Conference Secretary:
Attn: Aneli Fourie; Tel:  +27(21) 808-3174, E-mail: aef2@sun.ac.za