Registration Form for Imagine Photo Inspire

Program-ID : 142784


Last Name: ___________________________________________________

First Name: __________________________________________________

Company: _____________________________________________________

VAI-ID-No. (if applicable) ___________________________________

Address: _____________________________________________________

Postal Code and City: ________________________________________

Country: _____________________________________________________

Phone: _______________________________________________________

Fax: _________________________________________________________

E-Mail: ______________________________________________________


How would you like to receive the registration key?

e-mail - fax - postal mail


How would you like to pay the registration fee:

credit card - wire transfer - check - cash

Credit Card Information (if applicable)

Credit Cards: Visa - Eurocard/Mastercard - American Express - 

Diners Club

Card Holder: _________________________________________________

Card No.: ____________________________________________________

Expiration Date: _____________________________________________

Date / Signature: ____________________________________________