To: Stichting WIC, Amsterdam, The Netherlands
attn: Financial Department

Please charge my credit card

for the amount of: NLG _____________________

Re: ANTS IV registration fee

creditcardnumber	_______________________________________________
	(  ) VISA     (  ) Mastercard/Eurocard    (  ) American Express
expiration date	_______________________________________________
name creditcardholder	_______________________________________________
address creditcardholder	_______________________________________________
postal code + domicile	_______________________________________________
country	_______________________________________________
signature	_______________________________________________

please print this form, fill it out, and send it by fax to:

fax + 31 20 5924199

of Stichting WIC, Amsterdam, The Netherlands