AUTHORISATION FOR PAYMENT BY CREDIT CARD
I hereby authorize that my Credit Card Account be debited in favour of POLYCHAR with the amount as indicated hereunder in respect of my enrolment and registration fee for the POLYCHAR 22:  World Forum on Advanced Materials that will be held in Stellenbosch, South Africa from 7-11 April 2014.
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: Mrs Aneli Fourie; Tel:  +27(21) 808-3174, Fax:  +27(21) 808-4967 
E-mail: aef2@sun.ac.za