Membership Form
UK RESIDENTS ONLY
Personal Information
Name
*
First Name
Last Name
Mobile Phone Number
*
Email Address
*
Address
*
House Number or Name
Street Address Line 2
City
State / Province
Post Code
Date of Birth
*
/
Day
/
Month
Year
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Your Bank Sort Code
*
Your Bank Account Number
*
Payments
Payments must be made by 23rd of each month - amounts may be varied at any time
Monthly Payment
*
Any amount between £4.33 & £26.00
Date you intend to make payment
*
1st to 23rd - this will help me monitor receipts
How often would you like to recieve your winnings?
Monthly (default option)
Half Yearly (January & July)
When Prize Fund exceeds £25
When Prize Fund exceeds £50
Other Information
How did you hear about this lottery syndicate?
e.g. Facebook, Web Search, Recommended by a friend
How did you hear about this lottery syndicate?
Facebook
Web Search
Recommended by a friend
Business card
Other
Payment dates:
*
I understand that payments must be made by 23rd of each month for entry to next month's draws
Payments
*
I understand that I can pause, resume and change payments at any time. Payee bank details will be shown on the form submission page.
Rules
*
I confirm that I have read the Syndicate Rules
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*
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