I would like to make a donation to INCTR.

Please charge my credit card for the total amount of: _____________

Indicate the type of currency (tick one box):
Euros
USD

Indicate the type of credit card (tick one box):
American Express
Visa
Mastercard
Eurocard

Credit card number: _________________________
Expiration Date:_________

Name of credit card holder (as it appears on the credit card):
__________________________________________________________
Signature: ______________________________
Date (dd/mm/yy): ____________

Please print this form and fax it to INCTR, attention Elisabeth Dupont or Suzanne Eloot at 32 2 373 93 10 or send it by post to INCTR at the following address:

INCTR at Institut Pasteur
Attention: Elisabeth Dupont/Suzanne Eloot
Rue Engeland 642
B-1180 Brussels
BELGIUM

Thank you for your kind and generous support of INCTR.