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Section 1

print and complete white boxes only - leave sections 2 and 3 blank
Department Name


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:

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.
Credit CardI wish to pay by VISA MasterCard (tick one)
Under no circumstances can American Express be accepted.
Card holder name ____________________________________________
Card number
Start date
Expiry date
Card issue number
(if applicable)
Billing address


Signature of cardholder
VAT number (if EU institution/company) ____________________________________________

Section 5

Card CVV security code*
*The last 3 digits on the back of your card.
This page last modified 13 May, 2016 by Survey Web Administrator.