Linkup Event Payment Form

Each centre receiving the Linkup in Australia and New Zealand has agreed to pay per PWK attending their satellite linkup event. This will cover the costs incurred in receiving the linkup from the Event origin to Australia and then up-linking to the Optus B3 satellite. Please send $5 per PWK attending to Resource Media using this form to identify the centre, PWK attendance & method of payment.

Name of the Event: Conversations Event

Payment Method (Please place an "X" in the appropriate boxes)

[  ] Credit Card
(If paying by credit card please fax, post this form or FirstClass it to Debbie Cations)

[  ] Visa      [  ] M/Card      [  ] B/Card
Cardholders Name (exactly as on Credit Card):
Credit card number:
Expiry date:
Phone number:
Signature (if faxing or mailing):

[ x ] Cheque
Please fill out this form and post it with your cheque.
      Date:       14/3/05M
      Amount     200.00

[  ] Electronic Funds Transfer
      Amount transferred:

[  ] Direct Deposit
Please include a reference to indicate what the deposit is for eg Tokyo Linkup to Sydney.

Account details for Electronic Fund Transfers and Direct Deposits

Mailing Address for Cheques or Credit Card Details

Dear Andrew, Am I to assume this payment form will also act as receipt? Have photo copied if so. John