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CREDIT CARD PROCESSING FORM
Do not email this form - send by post

Section 1	print and complete white boxes only - leave sections 2 and 3 blank
Department Name SURVEY OF ENGLISH USAGE Contact Sean Wallis Phone x33119 (020 7679 3119) Total amount to be charged in Pounds Sterling (GBP) ____________________________________________ Payment for (indicate) ICE-GB ICE-GB Sound DCPSE IGE Landmarks Project 504971 Task 100 Award   156822   Expenditure Number 14040
Section 2
For Internal Use Only - Survey of English Usage, UCL Details confirmed by department:   Date:
Section 3
For Internal Use Only - Financial Services Office, UCL Received:   Mail Order/CSC/AVS Processed:   FSO Stamp Processed by:   Receipt no: SN
Section 4
For your security Sections 4 and 5 are destroyed after processing has been completed. This form must be sent by post, not email.
I wish to pay by VISA MasterCard (tick one) Under no circumstances can American Express be accepted.
Card holder name	____________________________________________
Card number
Start date (mm/yy)	/
Expiry date (mm/yy)	/
Card issue number (if applicable)		NO CVC! The number on the back of your card is not required.
Billing address	____________________________________________ ____________________________________________
Signature of cardholder	____________________________________________
VAT number (if EU institution/company)	____________________________________________