Congress: XV UISPP Congress

   Name of Participant:

   I (name of the Credit Card Holder) ____________________________________________

   authorize TopAtlântico Operated by TopTours to charge the amount of € ( Euro )

   ___________________ to my credit card.

   I also authorize that my credit card be debited or credited in the amount of any subsequent
   changes.

   Visa Amex Mastercard Other_________________________________

   Nº |__|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__| Exp. date. |__|__| / |__|__|

   The three last digits printed on the back of the card (except Amex) |__|__|__|

   Cardholder’s birthdate ______/______/______
    (Day) (Month) (Year)

   Billing Address _________________________________________________________

   ______________________________________________________________________

   _____________________________________________ Date ______/_______/______

             (Cardholder’s signature, as on the card)                      (Day) (Month) (Year)