Lottery Application Form

St. Joseph's Hospice Lottery
Today's Date:

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Date
Contact Name*

TitleFirst NameLast Name
Address*

Street Address

Street Address Line 2

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Phone Number*

Area CodePhone Number
E-mail*
Number of Chances per week (£2 per entry per week)*
No. of Chances
Payment*

£8.68 1st of every month for one chance per week£17.36 1st of every month for two chances per week£26.04 1st of every month for three chances per week
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Sort Code*
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Account Name*
Bank Address

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How did you hear about us?*
St. Joseph's Hospice would like to keep in touch with you about our services and initatives that may interest you. If you DO NOT want to hear from us by any of these means, please select the relevant box(es) below:

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Players must be aged 18 years or over and resident in Great Britain*

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Please gamble responsibility, visit www.gambleware.co.uk for further information. For full terms and conditions of the St. Joseph's Lottery, please visit www.stjhospice.org.uk
Signature*

St. Joseph's Hospice Lottery