Engage Standing Order Mandate

Credit Card Payment Form for Personal or Organisational Subscription

Please return your completed form to: engage, Rich Mix, 35-47 Bethnal Green Road, London E1 6LA.

Please complete this form in BLOCK CAPITALS Please charge this credit card as set out below:

Individual / Organisational* Membership Subscription

Member Details (If you have submitted your information via engage’s website www.engage.org, you only need to fill in the NAME and AREA details**) **Member Name / s ______**Organisation Name (if relevant) ______Address ______Tel Work ______Tel Home ______Email ______

Payment Details

Amount of payment: £ ______(UK£ Sterling amounts only) Type of Credit Card Visa Mastercard/Switch Visa Delta* (NB: these are the only types of card accepted) Card Number ______Expiry Date _ _ / _ _ Security Code _ _ _ ( last three digits on signature strip) Issuing Bank ______Name of cardholder ______Address of cardholder______Signature of cardholder ______*Delete as appropriate