| Name |
________________________________________ |
Company |
_________________________________________ |
Address:
City, State, Zip,
Country: |
__________________________________________________________________________________
_________________________________________ |
Phone: |
______________________________________ |
| Fax: |
________________________________________ |
| E-mail: |
_________________________________________
|
| # of participants: |
_______ x U.S. $650 = $ _______________ |
PAYMENT
OPTIONS: 1) By Check:
(MAIL IN)
|
Mail check (U.S. Dollars) and copy of
this completed form to:
IBC - Italian Conference
5148 Leesburg Pike
Alexandria, Virginia USA 22302
To arrange for payment in Italy, contact:
Mr. Ermanno Brocardo
TEL: 39-33-88-642-0029
FAX: 39-19-848-4610 |
| 2) Credit Card:
FAX TO:
703-820-2720 |
__MasterCard __Visa __ American Express (choose
one) Credit
Card#: ___________________________________
Expiration Date:
_________________________________
Name on card:
__________________________________
Cardholder
Signature:
_______________________________________________
|
