The Powerlist Black Excellence Gala

Name*

First NameLast Name

Company (if applicable)*

Company NameJob Title

E-mail*

Phone*

Include ext.

Address*

Select Ticket*

Single Ticket – £630.00 + VATTable of 10 – £5995.00 + VAT

Number of Tickets*

Please indicate the number of tickets / tables you require. Please send guest names via e-mail.

Dietary Requirements*

Tables - Please send full list via e-mail.

Confirmation*

I understand that the choices indicated above are subject to availability on a first come, first served basis and that I will be contacted by the organiser for confirmation and ticket payment arrangements.

Payment Method*

Bank TransferCheque

Payment Details - Please inform upon completion

Powerful Media Ltd.

2nd Floor Cumbrian House, 217 Marsh Wall, London E14 9FJ

Sort code: 40-06-02

Account Number: 73908380

Tel: +44 (0) 207 531 4960

Terms and Conditions

PLEASE READ AND ACCEPT THESE TERMS & CONDITIONS

Acceptance*

Bookings may only be made by completing a booking form in full and are not accepted until written confirmation has been sent by Powerful Media Ltd. ("the Organiser")

Cancellations*

Can be made up to 20 working days prior to the event. Cancellations must be confirmed in writing and will be subject to a 30% cancellation charge. Cancellations after that date will be subject to full payment. Non-payment or non-attendance does not constitute cancellation. It may be necessary for reasons beyond the control of the organisers to alter the content and timing or location of the event.

Alternative names*

May be sent for your booking at any time.

Abandonment or Relocation.*

In the event that the Gala is abandoned for whatever reason the Organiser shall refund any bookings it has received from applicants for places,who shall have no other claim whatsoever against the Organiser.

Other Arrangements*

If you have any requirements, such as wheelchair access or special dietary needs, please let us know in advance.

Signature: (Use mouse / finger to sign)*

Date and Time*

MonthDayYearHourMinutesAM/PM Option