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4733925-10477500?10.00 Cash Back Claim form (rev 03/20) This form can be completed if you have attended a sporting or leisure event and wish to claim ?10.00 under the cashback scheme. Please see the Terms & Conditions below before completing this form.A receipt for the event MUST be attached. My CSSC Membership number is:(must be provided)My employing Department is (or if retired, please state):Please also provide office address The event I am claiming for is: Date of Event that I’m Claiming forNameAddressPostcodeE-mail/TelI confirm that I will not claim for this event from any other sourceSigned Date T & Cs There must be a minimum spend of ?20 in order to claim ?10 backNo alcohol, holidays or meals (only exception is “team meals” e.g. works Christmas parties). Cannot be used for a further discount on an already discounted CSSC event or offer.The full value of the claim must be for the sole benefit of the member only.Members may only claim twice during a calendar year (Jan – Dec). Claims can only be made after you have attended the event.Claims must be submitted within 4 weeks from date of activity attended.Every effort will be made to deal with your claim as soon as possible, but please allow up to 4 weeks for your claim to be processed. Once completed, scan in your receipt/ticket and attach along with this form and email to: cashback.derbynotts@csscvolunteer.co.uk or send with proof of your purchase to: Jackie Whitham, 16 Caernarvon Close, Walton, Chesterfield, Derbyshire S40 3DY. Our preferred, quickest, easiest and safest way of paying your claim is by bank transfer. If you require payment by cheque a stamped, self-addressed envelope must accompany this claim. If not a postage charge of ?1 will be deducted from your claim.Treasurer to Complete Date paid:Cheque No:Bank TransferClaimant to CompleteSort CodeAccount NumberName on Bank Account ................
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