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: emills@providencerow.org.uk
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.