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Lottery Application Form

Please complete the following form, print it out, and send to: Devon Air Ambulance Trust, Unit 5 Sandpiper Court, Harrington Lane, Exeter, Devon EX4 8NS. Telephone: 01392 466666. DO NOT SEND TO YOUR BANK PLEASE

Title   Full Name
Address
(inc. postcode)
Telephone   Email
Signed
 

Cheques should be made payable to DAAT Lottery.
Please tick desired future payment method below.

Standing Order Please complete mandate below
Standing Order by internet Please sign, date and return form
Cheque amount enclosed £

Entry to the lottery is based on a payment of £1 per week. Cheques or standing order payments can be made annually, six monthly or quarterly. Standing orders can also be monthly. If you pay by cheque we will remind you in good time.

Standing Order Mandate
To Bank (Bank Name)
Bank Address (inc. Postcode)
Account Name
Account No  Sort Code
   

Please debit my above account and pay: DAAT Lottery, HSBC, St Thomas, Exeter. Sort Code: 40-20-29 Account No: 11377566 thesumof(pleasetickappropriatebox):

£52 annually £26 six monthly £13 quarterly £4.34 monthly

on (start date) ,untilyoureceivefurther notice from us in writing.
Signature Date

We would like to use the winner's name and location in promotional material. If you do not want your name used please tick this box.
 Please tick this box if you wish to receive mail from carefully selected companies regarding products or services which we think may be of interest to you.

FOR BANK USE ONLY
Please quote the following reference Membership Number :