UCL logo
 

PrintCREDIT CARD PROCESSING FORM

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.
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
(mm/yy)
   
/
   
Expiry date
(mm/yy)
   
/
   
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 12 September, 2014 by Survey Web Administrator.