Creditcard data form

Please fill the following creditform and send it to us via fax or regular mail to:

Institut fuer Allgemeine Psychologie

Fechner Day 2001

Seeburgstrasse 14-20

04103 Leipzig

Germany

fax: +49(341) 9735969

Please insert the same kind of payment, membership, student donation and scientist donation as in your registration form.

You can download the creditform as PDF under Creditform

Items with a (*) have to be entered !

Registrationkey if available: *

Cardtype: *

Cardnumber*:

Cardholder (Fullname):

KPN number (3digits) help:

Expiry date (not earlier 10/2001)*:

Kind of payment: *

ISP Membership already paid ? *

[100 DM] YES:NO:

Student stipend donation:

Sponsoring for scientists from Eastern Europe and Russia:

Sightseeing Dresden:

YES:

NO :

Total