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Credit / Debit Card Payment Form |
Please print this page, complete the form
and send it by fax or post to:
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Lewis School of English
33
Palmerston Road
Southampton
SO14 1LL
UK |
Tel: +44
23 8022 8203
Fax: +44
23 8023 1395 |
For a Microsoft Word version of this page
(31kb),
click here.
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Please calculate the
total amount payable. A 2% premium will be added to all payment by credit
card.
Total: £
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Name of student
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_______________________________________________________ |
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Address |
_______________________________________________________ |
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Start date |
_______________________________________________________ |
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Please charge
£ __________ to my |
o Diners Club
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o
Visa |
o
Mastercard |
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o
Switch |
o
Maestro |
o
Solo |
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o
JCB |
(please tick
ü) |
Type of card:
credit card
o
debit card o
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Card number
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__ __ __
__ - __ __ __ __ - __ __ __ __ - __ __ __ __
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Expiry date (mm/yy) |
__ __ /
__ __ |
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Cardholder's name
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_______________________________________________________
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Cardholder's address
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_______________________________________________________
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Cardholder's
telephone number
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_______________________________________________________
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Cardholder's signature |
_______________________________ |
Date |
____________ |
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