Inter-Disciplinary.Net

Personal Details

Full Name: ___________________________________________
(Enter your name exactly as it appears on the card)

Company: ___________________________________________
(If applicable)

Billing Address:
(Enter the address as it appears on your credit card statements)

_________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

City: ____________________________________________________

State/County: _____________________________________________

Country: ____________________ Post/Zip Code_________________

Tel: ________________________ Fax: ________________________

E-mail: __________________________________________________

Credit Card Details

Type of Card: _____________________________________________
(e.g., Visa, Mastercard: we cannot accept Amex)

Card Number: _____________________________________________
(Please write clearly)

Valid From: ____________________ Expiry Date: _________________

Security Number: _______
(The last three digits on the strip on the reverse side of the card)

Bank Name on the back of the credit card: ________________________

Amount to be Debited

Please write here in numbers the amount to be debited:

________________ (e.g, 225.00)

Please write here in letters the amount to be debited:

________________________________________
(e.g., one hundred and twenty five pounds)

I hereby authorise Inter-Disciplinary.Net to take the sum stated from my credit card. I have read and agree to the terms and conditions as laid out in the Cancellation Policy stated in the booking form. I have read and agree to the credit card payments notes contained in the section below.

Signature:

__________________________________

Date:

__________________________________

Credit Card Payments Notes

1. Inter-Disciplinary.Net will issue an invoice with respect to your participation in the conference.
2. Your credit card will be charged 3 days after the invoice has been issued.
3. Any errors in the invoice must be notified to Inter-Disciplinary.Net by fax or email within 72 hours of receipt.
4. Any changes to the booking, additional services requested, or other changes to the services and items stated in the invoice must be notified at the earliest opportunity.
5. Once your credit card has been charged, Inter-Disciplinary.Net will destroy this authorisation form with immediate effect. Inter-Disciplinary.Net will not retain any record of your credit card details.
6. Refunds. Where refunds are agreed, Inter-Disciplinary.Net will only refund the card from which the original charge was taken. Refunds are subject to a £5 administrative fee.
7. Cancellations. Cancellations will be refunded in accordance with the terms of the cancellation policy stated in the booking form. Where a cancellation refund is agreed, Inter-Disciplinary.Net will only refund the card from which the original charge was taken.Cancellation refunds are subject to a £5 administrative fee.