WWH Logo

Lottery Application Form

Mr/Mrs/Ms/Miss/Dr Forename

Surname

Address

 

 

Post Code

Tel. No.

  • I confirm that I am aged 16 years or over

Signed

 

I wish to pay by (Please tick as appropriate)

  • Enclosed Cheque (Minimum £4.00)
  • Standing Order (Please complete form below)
  • Collector Service (Limited availability - £4.00 paid every 4 weeks to our collector who will call at your home)

Standing Order Form

Bank Name

Branch Address

 

Sort Code

Account Name

Account Number

Please debit my above account and send to:
National Westminster Bank PLC
Warrington Street
Ashton-under-Lyne, OL6 6JL

Account Number: 60710322  Sort Code: 01-00-39

The amount of:

  • £4.34 monthly
  • £13.00 quarterly
  • £26.00 half-yearly
  • £52.00 annually

until further notice quoting Reference
(this will be completed by the Lottery Office)

First payment on

Signed

Date

Please return to: Lottery Manager, Willow Wood Hospice, Willow Wood Close, Ashton-under-Lyne, OL6 6SL

NOT TO YOUR BANK