ECMTA-02              PAYMENT AUTHORISATION FORM


Payment of the registration fees for (names):

DEBIT AUTHORISATION

Credit Card (please circle one): Visa - Eurocard - MasterCard - Maestro
Card Number:
Expiry Date:
Name (as it appears on the card):
I authorise Sunland to debit my card of the amount of                 Euros.

Place and Date:
Signature: