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Credit Card Payment Form

 

Request to pay personal membership fees to EPSO by credit card 

I wish to pay my personal membership fee by:

(please tick)

⎕ MASTERCARD
⎕ VISA                             
  

Personal membership fees: 

 (please tick)

                   
⎕ 100 €    Professional                 
⎕   60 €    Postdoc.                         
⎕   40 €    Student 
 

Total amount to be charged to my credit card is:      €

Credit Card Details:

Name of member:
 
Credit Card Holder’s Name:
 
Card Number:
 
Expiry Date:
 
CVC-code (last 3 digits of the number on the back of your credit card):
 
Date:                      Signature:
 
 
Please print using the 'print view' at the top of this page above the main menu bar and fax this form to: + 32 (0)2 213 62 69
 
 
Upon receipt of your signed fax, EPSO will charge the membership fee to your credit card and confirm to you when the transfer arrives on the EPSO accounts.
 
You will then receive from us your login information to access the Members’ only section of the EPSO website.
 
 
Mailing address: EPSO, Rue de l’Industrie 4, 1000 Brussels, Tel: +32 (0)2 213 62 60,
 
 

Printed from http://www.epsoweb.org/credit-card-payment-form on 17/05/12 11:12:55 AM

EPSO is an independent academic organisation currently representing 61 institutional members bringing together more than 204 research institutes, departments and universities from 29 countries in Europe and beyond.