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Last Name: _________________________
First Name: _________________________
E-mail: _________________________
Mailing Address: _________________________
_________________________
Card type: ( ) Visa / ( ) Master Card / ( ) American Express
Credit Card N.: _________________________
Expiry date: _________________________
Name (as it appears on card): _________________________
Hotel/housing deposit E ______
Reservation fee E 7.30
Bank charges E ______ (5% of deposit)
Total amount E ______
I authorize the use of my credit card for this purpose
Date: ____________________ Signature: ____________________