Service Provider Registration Form / European Campus Card Association

Name of Company*

Address*

Country:*

Primary Representative*

Email*

Corporate Website:

Additional Representative Name Characters left: 1000

Additional Representative Email Address

Please give any brief details of Company’s products/services provided:

Payment Details - Payment by Invoice: Annual Membership Fee per Institution: €1,000.00. Your Purchase Order No.:

Please provide details of who this Invoice should be sent to. Email:*

^* - required