DEBIT CARD TEMPLATE - DOC by seeme22

VIEWS: 139 PAGES: 1

									    Mail Order Card Payment

Name:
Address:(Must include Post Code and House number as
recorded with Bank)



Card Holder
Name
(if Differs)
Main Card No:
(across centre
of card)
Card Type          Mastercard   Visa   Visa Electron
Please indicate.   JCB     Solo
(Issue no
Switch only)       Switch/Maestro
Start Date
Expiry Date
Amount to Pay
(GBP only)         £
Dept Name &        Modern Languages/ Beverly Tribbick
Ext No.            15961
Reason for         Symposium/Accommodation Fee
Payment            ‘Writing under Socialism’
Account/Project
Codes to Credit    SH2423
Date
Security Code
(last 3 digits on
Sig Strip on
reverse – please
destroy after
input)
      Please note no other documentation needed with
      this form

								
To top