SEASON CARD HOLDER DETAILS Please note each applicant must make a separate application. Download additional application forms at leytonorient.com. Please note all information below is required. Mr / Mrs / Miss / Ms / Master / Other Customer Number: First Name: Surname: Address: Postcode: DOB: Telephone Number: Email Address: □ I was a 2020/21 Season Card Holder and applied to bring forward credit to contribute towards the payment of my 2021/22 Season Card. Please note those wishing to bring forward a credit MUST apply via this application form and NOT via the online payment process at www.onlyoneorient.com. PRICES Qualiteach Community Stand** Adult (25-64) £189 Concession* £135 Under 18 £99 Under 11 £49 Q2W Tommy Johnston South Stand Adult (25-64) £305 Concession* £199 Under 18 £99 Under 11 £49 Green Inc East Stand / Justin Edinburgh Stand Adult (25-64) £330 Concession* £209 Under 18 £99 Under 11 £49 Legends’ Lounge 21/22 Price Adult (25-64) £620 Concession* £449 Under 18 £449 Under 11 £449 *Concession applies to those 65+, Young Adults (18-24), Emergency Services, Armed Forces, NHS Staff, Waltham Forest Council employees, second parents, students and the unemployed. Proof of eligibility must accompany applications and must be dated within the last two months. Emergency Services applies to the police, ambulance and fire services. **The Qualiteach Community Stand is the Club’s Family Stand. Single person applications will not be accepted and Adults and Concessions can only purchase with an Under-18 or Under-11 Season Card. All 2020/21 Season Card Holders’ seats will be held until 10pm Wednesday 30 th June at which point seats will be released for general sale. CURRENT SEASON CARD HOLDERS □ I would like to renew my existing seat for the 2021/22 Season and my seat details are: Stand: Row: Seat Number: SEASON CARD TYPE: Adult: □ Young Adult: □ Senior: □ Emergency Services, Armed Forces & NHS Staff: □ Second Parent: □ Waltham Forest Council Employee: □ Unemployed: □ Under-18: □ Under-11: □ Carer: □ *Proof of age must accompany all NEW applications. Proof of status must also accompany this application and be dated within the last 2 months. *Please circle category where more than one is listed. NEW SEASON CARDS OR MOVING LOCATION New Season Card Holders or current Season Card Holders wishing to move location. Seat Selection availability near the half-way line is very limited. Please list a range of block choices. □ I would like to apply for my Season Card in the following area: Choice 1: Stand: Block: Front: □ Middle: □ Back: □ Wheelchair: □ Choice 2: Stand: Block: Front: □ Middle: □ Back: □ Wheelchair: □ SEASON CARD TYPE: Adult: □ Young Adult: □ Senior: □ Emergency Services, Armed Forces & NHS Staff: □ Second Parent: □ Waltham Forest Council Employee: □ Unemployed: □ Under-18: □ Under-11: □ Carer: □ SEASON CARDS PAYMENT DETAILS □ I enclose a cheque for £ made payable to Leyton Orient FC. □ I enclose cash to the value of £ □ I authorise Leyton Orient Football Club to debit the card below for £ Card type: Mastercard: □ Visa: □ Visa Debit: □ (Amex not accepted) Card Number: Expiry Date: / Security Code: □ I authorise Leyton Orient Football Club to set up a monthly Direct Debit for the total sum of : £ For Direct Debit payments, please complete mandate form at the end of this document. EXTRAS □ I would like to purchase a £10 seat sticker with the following name*: □ I would like my Season Card to be posted by Special Delivery priced £7.00 per ticket. □ I would like my Season Card held for collection from the Club. Collection dates will be announced in due course. *Please note anyone who purchased a seat sticker for the 2020/21 season will receive a complimentary sticker for the 2021/22 season. DONATIONS The Leyton Orient Trust delivers football and sports programmes within the Waltham Forest community that engage, motivate and benefit thousands of children each year, including many disadvantaged and disabled young people. □ I would like to make a donation of £ to the Leyton Orient Trust to help in their work. □ I authorise my donation to be charged to the card supplied in Payment Details. □ I enclose a separate cheque for my donation made payable to Leyton Orient Trust (LOT). □ I am a UK taxpayer and I want the named charity to treat all donations I’ve made or will make from this date of this declaration, as Gift Aid donations, until I notify you otherwise. Signed: EXTRAS AND DONATIONS PAYMENT DETAILS □ I enclose a cheque for £ made payable to Leyton Orient FC. □ I enclose cash of the value of £ □ I authorise Leyton Orient Football Club to debit the card below for £ Card type: Mastercard: □ Visa: □ Visa Debit: □ (Amex not accepted) Card Number: Expiry Date: / Security Code: Only applicable to Junior Season Card Applications All 2021/22 Junior Season Card Holders are entitled to claim their complimentary Theo’s Family membership for the 2021/22 Season. This season’s Theo’s Family Membership includes a welcome pack which contains the below exclusive gifts: Theo’s Tots (Ages 3 and under) Theo’s Tykes (Ages 4-8) Theo’s Titans (Ages 9+) Teddy Bear Rucksack Powerbank Squad Poster Squad Poster Squad Poster Drinks Bottle Drinks Bottle Drinks Bottle All 2021/22 Theo’s Family memberships also include access to exclusive giveaways, competitions and events such as our Junior Christmas Party at the end of the year. □ I wish to claim the complimentary 2021/22 Theo’s Family Membership with this Junior Season Card Application. THEO’S FAMILY MEMBERSHIP TYPE: Tots (Ages 3 and under): □ Tykes (Ages 4-8): □ Titans (Ages 9+): □ ONE OF OUR OWN MEMBERSHIP Our newly launched ‘One of Our Own’ membership aims to support the ongoing success of the Leyton Orient Academy. The proceeds of the membership, which costs just £10 per month, will go directly to the Academy for dedicated use on selected projects, equipment and the general running of its successful operation. This limited availability membership includes all of the following benefits: • A limited-edition pin badge • Your name on a dedicated page on our website • Your name on a dedicated page of our matchday programmes • Your name on our ‘One of Our Own’ membership display in the Club reception (if you become a member by June 30th). □ I would like to become a One of Our Own member by signing up to a £10 per month Direct Debit. (Where memberships are available). For Direct Debit payments, please complete mandate form at the end of this document. For more information on Direct Debits please visit www.leytonorient.com/direct-debit HOW TO APPLY Apply online: www.leytonorient.com/seasoncards2122 or email your form to [email protected]. In person: Club Superstore at The Breyer Group Stadium. During advertised opening hours which can be found at www.shop.leytonorient.com. By post: Please return this application form and payment (cheques made payable to ‘Leyton Orient FC’) to Season Card Applications, Leyton Orient FC, The Breyer Group Stadium, Brisbane Road, Leyton, London, E10 5NF. KEEP UPDATED WITH THE O’S We would love to keep you informed of all the latest Leyton Orient news, highlights and special offers. Please indicate how you would like us to keep in touch: Email: □ Post: □ SMS: □ Phone: □ (Tick methods we can use to contact you) Instruction to your Bank or Building Society to pay by Direct Debit Please fill in the whole form and send it to: Leyton Orient Football Club Limited Breyer Group Stadium Brisbane Road Leyton Service User Number London E10 5NF 1 7 9 7 6 4 Name(s) of Account Holder(s) Reference Bank/Building Society account number Instruction to your Bank or Building Society Please pay L&Z Re Leyton Orient FC. Direct Debits from the account detailed in this Instruction subject to the safeguards assured Branch Sort Code by the Direct Debit Guarantee. I understand that this Instruction may remain with L&Z Re Leyton Orient FC and, if so, details will be passed electronically to my Bank/Building Society. Name and full postal address of your Bank or Building Society To: The Manager Bank/Building Society Signature(s) Address Date Postcode Banks and Building Societies may not accept Direct Debit Instructions for some types of account. This guarantee should be detached and retained by the Payer The Direct Debit Guarantee • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits • If there are any changes to the amount, date or frequency of your Direct Debit L&Z re Leyton Orient FC will notify you 3 working days in advance of your account being debited or as otherwise agreed. If you request L&Z re Leyton Orient FC to collect a payment, confirmation of the amount and date will be given to you at the time of the request • If an error is made in the payment of your Direct Debit, by L&Z re Leyton Orient FC or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society -If you receive a refund you are not entitled to, you must pay it back when L&Z re Leyton Orient FC asks you to. • You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. LEYTON ORIENT FOOTBALL CLUB WWW.LEYTONORIENT.COM /LOFCOFFICIAL @LEYTONORIENTFC @LEYTONORIENTFC /USER/ORIENTOFFICIAL
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