Application Form

£3,000 Charity Lottery

Your name:	Tick preferred payment amount:
Your address:	CHEQUE	£52 (1 year)
		£26 (6 months)
City:		£13 (3 months)
Postcode:	Please make cheques payable to: St Gemma's & Wheatfields Lottery
Telephone:

Payments by standing order greatly reduce our overall bank and administration costs and allow more funds to go towards patient care. Should you wish to set up a standing order please complete the mandate below:

STANDING ORDER MANDATE

Please pay to the Ipswich Branch of Lloyds Bank for the credit of St Gemma's & Wheatfields Lottery, Account No: 3326072 and Sort Code 30-94-55 (please tick the box next to your choice)

£52	(fifty two pounds)	commencing now and thereafter every	52 weeks
£26	(twenty six pounds)	commencing now and thereafter every	26 weeks
£13	(thirteen pounds)	commencing now and thereafter every	13 weeks
£4.34	(four pounds and thirty four pence)	commencing now and thereafter every	month

first payment to commence immediately and payments continue until you receive further notice from me in writing. My bank details are:

Account No:

Sort Code:


Signature:	......................................................	Start date:	......../ ......../ ........

Name of bank:
Address of bank:

City:
Postcode:

For Bank Use Only

Bank Ref No.

Please print out this application form and send it to us at:

St Gemma's & Wheatfields Lottery, Grove Road, Headingley, Leeds LS6 2AE