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Lottery Application Form

Mr/Mrs/Ms/Miss/Dr  Forename:

Surname:

Address:

 

 

Post Code:

Tel. No:

Email:

  • 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