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Cressing Temple, Witham Road,Cressing, Nr Braintree CM77 8PD - page 2 / 2

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Booking form

Please complete the form below and return it to Anne Brown at the address shown below. Book early to avoid disappointment.

Pitch reservations

Please reserve _____________ pitch(es) at a total cost of £ are not reserved until payment is received.

___________________

. Please note that pitches

Payment details Cheque. I enclose a cheque (made payable to HRCC) for £ ________________________ Credit Card. I authorise you to debit my card to the amount of £ ____________________

Name on the card ___________________________________________________________________ Cardholder’s address_________________________________________________________________ _____________________________________________________Postcode ______________________

Card type

Visa Credit Card

Visa Debit card (or VISA Delta)

Mastercard

Switch/Maestro

Solo

Card number Valid from (mm/yy) Issue No. (if applicable)

/

Valid to (mm/yy)

/

Security No. (last 3 digits on reverse)

Contact details Name _______________________________________________________________________________

C o m p a n y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A d d r e s s _ _ _ E-mail _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P o s t c o d e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T e l e p h o n e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ M o b i l e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________________________________________________________________________________ BY SIGNING BELOW, YOU ARE AGREEING TO THE TERMS AND CONDITIONS STATED ON THIS FORM.

Signature Date _____________________________ _________________________________________ Helen Rollason Cancer Charity, Woodside, Broomfield Hospital, Chelmsford, Essex CM1 7ET. Tel: 01245 514325, fax: 01245 515028, e-mail: anne.brown@helenrollason.org.uk

www.helenrollason.org.uk

Registered charity number: 1052861

Helen Rollason Cancer Charity is a trading name of Helen Rollason Heal Cancer Charity.

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