BLC 2008 registration and card payment form ----------------------------------------------------------------------------- Name ----------------------------------------------------------------------------- Affiliation ----------------------------------------------------------------------------- Email ----------------------------------------------------------------------------- Registration fee amount (delete as appropriate) 10 pounds (Student) 40 pounds (BLC member) 45 pounds ----------------------------------------------------------------------------- Do you require accommodation in Newark Hall for the nights of 4 and 5 September? yes (51.66 pounds) no ----------------------------------------------------------------------------- Amount to pay (registration + accommodation, GBP only): ----------------------------------------------------------------------------- Paying by: card cheque bank transfer (delete as appropriate) -----------------------------for card payment ------------------------------- Card holder name (if differs) ----------------------------------------------------------------------------- Address (must include postcode and house number as recorded with your bank) ----------------------------------------------------------------------------- Main card number (across centre of card) ----------------------------------------------------------------------------- Card type Mastercard Visa Visa Electron JCB Solo (delete as appropriate) (and issue number - Switch only) Switch/Maestro ----------------------------------------------------------------------------- Start date ----------------------------------------------------------------------------- Expiry Date ----------------------------------------------------------------------------- Security Code (last 3 digits on signature strip on reverse) ----------------------------------------------------------------------------- Date -----------------------------------------------------------------------------