Subject: Event 89514- Pre Event Invoice 25885
Date: Mon, 20 Feb 2017 16:35:25 +0000

CREDIT CARD PAYMENT FORM

I hereby authorise the card details below to be used to settle the deposit/any additional/the full charges with Central Hall Westminster, London for the following event/s:

Booking Details:

Company Name:   ___________________________________

Event Name:     ___________________________________

Event Dates:    ___________________________________

Card Details:

* THIS FORM IS NOT VALID UNLESS A PHOTOCOPY OF THE FRONT & BACK OF THE CARD IS ATTACHED *

Card Type**:            _________________________________

Card Number:            _________________________________

Expiry Date:            _________________________________

Security Number:        _________________________________

Name as on Card:        _________________________________

Billing Address:        _________________________________

                                               ____________________________________________________

                                               ____________________________________________________

Telephone Number:       _________________________________

Total Amount to be processed: ___________________________________

* PLEASE ENSURE THE TOTAL AMOUNT TO BE PROCESSED INCLUDES THE APPROPRIATE SURCHARGE *

**A 2.5% surcharge is applied to all credit card payments except American Express which incurs a 5% surcharge**

Cardholder’s Signature: ____________________________________

   Full Name in Block Capitals: _________________________________

Authorisation Code:             __________________________________________________      (Internal Use Only).