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FORM FOR PAYMENT BY CREDIT CARD KomPlasTech 2013 Conference PERSONAL DATA NAME OF THE CONFERENCE PARTICIPANT NAME OF CARDHOLDER ADDRESS OF CARDHOLDER AMOUNT OF CONFERENCE FEE PLN CARD DATA TYPE OF THE CREDIT CARD CARD NUMBER 16 digits EXPIRY DATE mm/yy PAPER DATA PAPER REFERENCE NUMBER DATE SIGNATURE Please complete the form and return to Signed and scanned version to ukasz Sztangret Akademia G rniczo-Hutnicza al. Mickiewicza 30 30-059 Krak w POLAND szt agh.

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The name of the form conference is Form 1099.

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