Providence Row Quiz 2014 – Table Booking Form Name __________________________ Company __________________________ Email __________________________ Telephone __________________________ Address ___________________________________________________________________ __________________________ Postcode __________________________ One table costs £120 and is a maximum of six people per table and team. Registration fee includes a free drink and a meal, prepared by our clients. Team name: ______________________________ Please supply the names of all your team members: No. 1. 2. 3. 4. 5. 6. Full name Dietary Requirements Email address* *by supplying your email address you are agreeing to further contact from us. I enclose a cheque for £120 (payable to Providence Row) Please charge £120 to my credit/debit card Visa MasterCard Maestro Card Number Security Number (last three digits) Credit/Debit card details: Valid From: / Expiry Date: / Issue Number: ……… Cardholder Name (if different from above) ___________________________________________ Cardholder Address ___________________________________________ ________________________________________________________________________________ _____________________________________________ Post Code ____________________ Please return by March 14th 2014: The Fundraising Team Providence Row The Dellow Centre 82 Wentworth Street London, E1 7SA Or contact Emily Mills: Tel: 020 7422 6385, Email: firstname.lastname@example.org Providence Row is a charitable company limited by guarantee registered in England and Wales with company number 07452798 and registered charity number 1140192. Its registered office is at The Dellow Centre, 82 Wentworth Street, London, E1 7SA.