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					CREDIT/DEBIT CARD RECEIPT                              FOR INCOME OFFICE USE
CUSTOMER NOT PRESENT                                         Receipt Number:


DEPARTMENT OF                     …………Physics and Atronomy

CONTACT NAME AND TEL NO …………John Allison, +44-161-275 4170 or +44-1422-845624

DESCRIPTION OF CONFERENCE ………12th Geant4 Workshop

NAME OF REGISTRANT                    ……………………………………………………………………………

CREDIT CARD DETAILS

NAME ON CARD                         ……………………………………………………………………….……..
…
CARDHOLDERS ADDRESS                  ………………………………………………………………………..…….
(as per statement)
INC POSTCODE
                                     …………………………………………………………………

CARD ISSUED BY (BANK OR EQUIVALENT) ………………………………………………………………

CARD NUMBER (On the front of the card)………………………………………………………….…………..

SECURITY NUMBER:(On the back of the card) ……………………………………………………………….

CARD TYPE: VISA………………………….……. MASTERCARD………………………………………

                     SWITCH………………………….... CARD ISSUE NUMBER…………………………..…

                     VISA/DELTA……………..……….. JBC………………………………….…………………

                     SOLO………………….……………. CARD ISSUE NUMBER…………………………..…


VALID FROM DATE…………………………… EXPIRY DATE………………. AMOUNT…………..…….




Authorisation obtained?      YES/NO               CARDHOLDERS SIGNATURE:



                                                  ……………………………………..………………………………..

FINANCE CODE TO BE CREDITED                               SOURCE OF FUNDS

C      A      0      0   5   1   2    1   1   8    0



DEPOSITED BY (sign) …………………………………. DATE ……………………………………

Please attach an addressed pre-paid envelope if you require a receipt.
Please post this form to:       Income Office
                                University of Manchester
                                MANCHESTER M13 9PL
                                UK

				
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