CREDIT/DEBIT CARD RECEIPT
FOR INCOME OFFICE USE
CUSTOMER NOT PRESENT
Receipt Number:
TO BE FILLED IN BY UNIVERSITY DEPARTMENT HOLDING EVENT
DEPARTMENT OF …………………………………………………………………………………
CONTACT NAME AND TEL NO ………………………………………………………………….…………….
DESCRIPTION OF CONFERENCE ……………………………………………………………….……………..
………………………..……………………………………………………...
Please attach an addressed pre paid envelope if you require a receipt sending to the customer
FINANCE CODE TO BE CREDITED
SOURCE OF FUNDS
FOR INCOME OFFICE USE ONLY
REASON RETURNED
The card has been declined The card has expired The card number is invalid
Valid from/Expiry date missing No Issue Number No Finance Code quoted/Finance Code invalid
American Express/Discover Card The PDQ machine is not accepting the card
Other reason ………………………………………………………………….
CUSTOMER DETAILS
NAME ON CARD ……………………………………………………………………….……..
CARDHOLDERS ADDRESS ………………………………………………………………………..…….
(per statement)
INC POSTCODE …………………………………………………………………
CONTACT TELEPHONE ………………………………………………………………………………
CONTACT E MAIL ADDRESS ……………………………………………………..………………………..
AMOUNT £ ………………………. CARDHOLDERS SIGNATURE: …………………………….
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CARD ISSUED BY (BANK OR EQUIVALENT) ………………………………………………………………
CARD NUMBER (On the front of the card)………………………………………………………….…………..
SECURITY NUMBER:(On the back of the card) ……………………………………………………………….
CARD TYPE: VISA………………………….……. MASTERCARD………………………………………