Payment by Credit Card

VISA MasterCard

Amount in € ____________________________Card Holder ____________________________Card No. ____________________________Valid until (month/year) ____________________________Card Verification Value 2 (CVV2)* ____________________________

___________________________________________________________ Signature of Credit Card Holder

*Your “Card Verification Value 2 (CVV2)” consists of the last three digits of the number on the back of your credit card near your signature:

Attention: Much to our regret we must inform you that credit cards issued in the following countries have recently been excluded from non-personal money transfer by the respective credit card companies:

Asia: Eastern Europe: Western Europe: Africa:Indonesia Romania Great Britain Ivory CoastPhilippines Bulgaria Netherlands Ghana

Lithuania NigeriaKazakhstan EgyptUkraineBalkans (former Yugoslavia)

Please fill in this form completely and legibly and send the original form to uni-assist.

IMPORTANT!:

Please send the original copy of the form to uni-assist, never a scanned or faxed copy!

This form has to be filled in by the owner of the credit card and the bank account respectively.