\documentclass{article}
\usepackage{a4wide}
\begin{document}
\thispagestyle{empty}

\vfill

\begin{center}
{\LARGE \bf AVoCS 2009 registration and card payment form}
\end{center}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
{\bf Name}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Affiliation}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Email}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Registration fee amount
  \hfill    \pounds 280 \hfill
}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Paying by} \hfill card \hfill cheque \hfill bank transfer\\
(delete as appropriate)
\begin{verbatim}
----------------------------- for card payment ---------------------------------------
\end{verbatim}
\noindent
{\bf Card holder name (if differs)}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Address (must include postcode \\
and house number as recorded with \\
your bank)}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Main card number\\
(across centre of card)}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Card type}  \hfill Mastercard \hfill Visa \hfill Visa Electron \hfill JCB \hfill Solo \\
(delete as appropriate)\\
{\bf (and issue number -  Switch only)} \hfill Switch/Maestro
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Start date}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Expiry Date}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Security Code (last 3 digits
on signature strip on reverse)}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Date}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}
\noindent
{\bf Signature}
\begin{verbatim}
--------------------------------------------------------------------------------------
\end{verbatim}

\vfill

\end{document}