Amanda Patterson Creative Writing Courses :: Membership :: THE WRITE CLUB - SUBSCRIPTION FORM

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THE WRITE CLUB - SUBSCRIPTION FORM

THE WRITE CLUB - SUBSCRIPTION FORM

FOR ONLY R155, 00 per month or R135, 00 for 2 years or take advantage of our discount – 12 months – R1 860, 00  Now you pay R1 674, 00  All prices exclude VAT
 
Please complete all the following information and fax to 011 706-4199. Form must be signed.

Credit Card Information

Card Type: VISA /MASTERCARD (Please circle)
 
 ID No.  __________________________________________________
 
Credit Card Number ________________________________________
 
Cardholder’s Name ________________________________________ 
 
Expiry Date ___________________
 
Security Code ________  (This a unique last 3 digit number on the back of the debit/credit card)
 
Telephone __________________________________  
 
Cell _______________________________________
 
Fax  _______________________________________
 
Email ______________________________________________
 
 
 
Signature ______________________________________________________________________
 
 
Date ___________________
 
 
Full Printed Name _____________________________________________
 
 
Witness ____________________________________________________
 
 
Date ___________________
 
 
Full Printed Name _____________________________________________
 
Ask for this amount to be debited from your credit card or pay us directly
    The Write Co
    Nedbank
    Benmore Branch, Code 197305
    Cheque Account, Code 1973045559
Fax proof of payment to 011) 706-4199