CREDIT CARD FORM - BRAZILIAN CIMPA SCHOOL


Registrant Full Name:_________________________________________________________


Credit Card: ( ) VISA     ( ) AMERICAN EXPRESS	


Card Number:__________________________________________________________________


Expiration date (dd-mm-yy):___________________________________________________


Name on Card:_________________________________________________________________


Identification document (for card identification purposes):___________________ 


I, the undersigned, authorize FUNDAÇÃO CEARENSE DE PESQUISA E CULTURA to charge
to the credit card indicated above the total amount of: R$__________ 


Signature: ______________________________________


Date (dd-mm-yy):_________________________________