Please Print this form
To
..D J SAMPSON. 81 HEATH LANE, BRINKLOW, RUGBY. CV23 0NX
Concessions are available for School Children, NUS card holders and Members of Brinklow Royal British Legion Club (You must show your cards);
My name is Mr/Mrs/Ms.....................................................................................I Wish To Book Tickets for The Wurzel Bush Folk Club.
....
Date of Event . , ....m .. Number of ..Adult Tickets .... n Number of Concessions ...... - - - - - - - Total Cost>MAY 12th .. . . . .............................. @ £5.00 ... .. ..................@ £3-00
I enclose a Cheque / Postal Order Payable to D.J. SAMPSON for
£ ........Please put your Name, Address and Bank Card Number on the back of your Cheque.
Plus a Stamped Addressed Envelope / or Please e-mail confirmation of ticket to be collected on door
my e-mail address is ...................................................................
Please Don't Leave it to the last moment allow 5 working days
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