Pay Back Claim Form s1

TYNE, WEAR & NORTHUMBERLAND AREA CASHBACK CLAIM FORM EVENT: Human League DATE & TIME: 04 December 2016 Doors open 7.00pm PAY BACK PER MEMBER – £15.00 CSSC MEMBER - HEAD OF PARTY: ……………………………………………………………………….. FULL NAMES OF ALL IN YOUR PARTY, INCLUDING YOURSELF FULL NAME CSSC No. Contact Tel No. Email address (H/W/M)

TOTAL NUMBERS TOTAL CLAIM £ (add rows if claiming for more than 10 members including yourself)

I certify that I am a member of CSSC Tyne, Wear & Northumberland Area and have booked tickets for Human League for the members on this claim form. I wish to claim a ‘cashback’ subsidy for each member.

All ‘cashbacks’ will be by BACs transfer. Please complete the details below and sign and date the claim form.

Account name: Account No: Sort Code:

Signature: Date:

Send with receipts to: Sheila Ramsay, 32 Allendale Drive, South Shields, NE34 7SX

N.B. Settlement of your claim will be made after the event has taken place; please allow a month before considering further contact.

For official use only:

Date paid: Payment Ref:

PTO IMPORTANT NOTES OVERLEAF – YOU MUST READ AND UNDERSTAND THEM!  ‘Pay back’ claims must only be made for CSSC TWN members  "Enter the CSSC number for all members". (Any member who does not know their membership number should contact CSSC Head Office on 01494 888415/418) work and mobile number  Any member found to have claimed a ‘pay back’ for non-member(s) attending the event may be suspended from membership.  All claims are on a ‘first received – first paid basis. Once claims for 30 members have been received, no more pay backs will be considered. Members should therefore be aware that they could potentially have to pay cost price for the event if the claim is received after 30 ‘cashback’ claims have been made.  For audit purposes, a post event % check will be undertaken to confirm that the CSSC TWN members on this form did, in fact, attend the event and a refund of the ‘pay back’ will be sought from the Head of Party for any member found not to have attended the event in their claim.