Title: C Method of Payment
Author: gilt
Last saved by: Svein Sture
Company: the University of Greenwich

Conference Registration and Payment Form for credit card only

Dear Participant, 
Thank you for your booking for the EBHA 12^th Annual Conference. To complete your registration, please fill in the below form and return it to the following post or email address:

University of Bergen
Department of AHKR
Att. Per Kristian Sebak
P.O.Box 7805
N-5020 Bergen
NORWAY			Email: per.sebak@ahkr.uib.no

Name of participant:

Booking fee, including conference dinner on Saturday evening, Aug. 23 (please tick):

Until May 31, 2008 (if you post the form by “snail mail”, the postmark must be May 25 at the latest)
EBHA members: | 1,000 NOK |
Non-EBHA members: | 1,200 NOK |
students: | 500 NOK |
	
After May 31, 2008
EBHA members: | 1,200 NOK |
Non-EBHA members: | 1,400 NOK |
students: | 700 NOK |

I will take part in the dinner August 23, YES | | NO | | with | | additional non-registered person(s)
The cost per additional non-registered person is 800 NOK | |

Payment, credit card (please tick):
VISA | | Mastercard | | American Express | | Diners |

Card No:

Expiry Date 
(MM/YY):

CVV2 code
(3 or 4 digits on back of card):

Amount Due (NOK):

Cardholder’s name (as it appears on card): | Signature (if posted by “snail mail”):
Cardholder’s address: