The Powerlist Black Excellence Gala

Name

First NameLast Name

Company (if applicable)

Company NameJob Title

E-mail

Phone

Include ext.

Address

Select Ticket

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

Payment Method

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

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

Abandonment or Relocation.

Other Arrangements

Signature: (Use mouse / finger to sign)

Date and Time

MonthDayYearHourMinutesAM/PM Option