FILM INDUSTRY FOOTBALL EVENT 2004

THE DEN, MILLWALL FOOTBALL CLUB

SUNDAY 23rd MAY 2004

ENTRY FORM

Please complete and return the form, by post or fax, to:

Chris Higgs

FIFE 2004

NCH

85 Highbury Park

London,

N5 1UD

Fax: 020 7704 7063

Please enter my team at £1,000. I understand that teams will be sold on a first come first served basis.

Entry price includes:-

  • entry to the five aside tournament at Millwall Football Club
  • 10 free spectator tickets.
  • Please also book me:-

    • ______ additional spectator tickets at £5 per person (also available on the day for team guests)

  • I/we cannot enter a team but wish to make a donation*

    • I enclose a cheque for the full amount of £___________, made payable to NCH

    or

    I wish to pay by:MastercardVisa Cardto the amount of £__________

    Card Number

    Authorisation digits (last 3 digits from the signature strip on reverse of card)

    Expiry Date:______________Today's Date:______________

    Name (as it appears on card): _____________________________________

    Signature:_____________________________________

    Team Contact Name:_____________________________________

    Address:_____________________________________

    _____________________________________

    __________________ Postcode:__________

    Daytime Tel Number:_____________________________________

    Email Address: _____________________________________

    All enquiries, please, to Chris Higgs at NCH on 020 7288 7837 or chris.higgs@nch.org.uk

    * ‰ I am a UK taxpayer and would like my donation to be treated as Gift Aid

    You can cancel this declaration at anytime by notifying NCH. You must pay an amount of income tax/capital gains tax at least equivalent to the tax that the charity reclaim on your donation in the tax year (currently 28p for each £1 you give)