WARNING: Please do not send this by e-mail for security reasons.

Credit Card Payment Form

For payment by credit card,
please print out this form, fill in the blanks and send by fax or air/surface mail
to
Masahiko Sato, DS2000
Graduate School of Informatics, Kyoto University
Kyoto 606-8501, JAPAN
FAX: +81-75-753-4954


CREDIT CARD INFORMATION
Card Type (Tick either one)
 		  [     ]  VISA                     [     ]  MasterCard 
Card Number  
Expiration Date  
Name of Card-holder
(as it appears on the card)		  
Billing Address
 
  		 

 
Name
___________________________________________________________________________________________

Affiliation
___________________________________________________________________________________________

Postal Address
___________________________________________________________________________________________

E-mail address
___________________________________________________________________________________________

Phone / Fax
___________________________________________________________________________________________

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