/IPSC-2012-Payment-Form

International Public Speaking Competition 2012 Monday 14 May 2012 – Friday 18 May 2012

Payment Form Competition organisers, participants and/or accompanying guests may complete this form and should submit it via e-mail to ipsc@esu.org by Friday 4 May 2012

Country

Your name Organiser / Participant / Accompanying Guest / Other (please select) E­mail Address Registration Fees

Description Participant Fee Accompanying Guest Fee (twin room) Accompanying Guest Fee (single room) Total Amount Due

Unit Cost £150 per person £300 per person £450 per person

Quantity

Total Cost

Payment Method 1: Credit / Debit Card Please Select (Y/N):

Card Type1 Card Number

Start Date End Date

Issue Number (Switch cards only)

Security Number (last three digits on the back of the card)

Cardholder Name (As it appears on your bank statement) Cardholder Address (As it appears on your bank statement)

Payment Method 2: Electronic Funds Transfer (EFT) / Bank Transfer Please Select (Y/N): •

Please transfer the value of the total amount due (above) to The English-Speaking Union.

Bank Name 1

Coutts & Co, 440 Strand, London WC2R

Mastercard, Visa, Switch or Maestro. We do not accept American Express.

Account Name Sort Code Account Number BIC (Bank Identifier Code) IBAN (International Bank Account Number)

0QS The English­Speaking Union of the Commonwealth 18­00­02 0181­7590 COUT­GB22 GB50­COUT­1800­0201­8175­90

Payment Method 3: Cheque / Bank Draft Please Select (Y/N): •

Please enclose a cheque / bank draft made payable to The English-Speaking Union for the value of the total amount due (above).

Payment Method 4: Payment On Arrival Please Select (Y/N):

•

If you would like to pay your registration fee(s) (or part thereof) on arrival, please contact the IPSC Convenor before Friday 4 May 2012.