Lottery Application Form
All profits from the lottery will go towards incredible care from Sue Ryder.
o If you would like to support your local Sue Ryder care centre with your lottery donation.
o
you
would like to support your local Sue Ryder care centre with your lottery donation.
TellIfus
here:
1. Your details (please print in block capitals)
Title:
First name:
Date of birth:
Surname:
Address:
Landline:
Mobile:
Email:
o If you do not wish your name to be publicised if you win (please tick here)
2. Number of lottery tickets
Please choose how many lottery entries you would like each week, and how you would like to pay for them:
1 lottery ticket:
o £4.34 every month
o £52 every year
2 lottery tickets:
o £8.68 every month
o £104 every year
3 lottery tickets:
o £13.02 every month
o £156 every year
4 lottery tickets:
o £17.36 every month
o £208 every year
3. Your consent to play (I confirm I am over 16 and resident of GB)
Signature:
The Sue Ryder Lottery is run and managed by Sue Ryder Lottery Limited which covenants all of its taxable profits to the charity
Sue Ryder. Responsible Person(s) Mr Neil Goulden & Mrs Heidi Travis, Sue Ryder Lottery Limited, 16 Upper Woburn Place, London,
WC1H 0AF. Players must be 16 and over. Tickets cost £1 each. Registered with the Gambling Commission under licence number
000-042085-N-321599-001. www.gamblingcommission.gov.uk www.gamcare.org.uk Please gamble responsibly. Sue Ryder is a
charity registered in England and Wales (1052076) and in Scotland (SC039578).
Date:
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4. Your contact preferences
We value your support and promise to respect your privacy.
The data we gather and hold is managed in accordance with the Data Protection Act (1998). We will only share your data with Sue Ryder and will not disclose or share personal
information supplied by you with any other third party organisation without your consent. Your support helps Sue Ryder continue its vital work.
Sue Ryder would like to keep in touch with you to tell you about its work and how you can support it. Please choose all the contact methods you are happy for Sue Ryder to use
by ticking the following boxes. The more you choose, the more relevant, cost-effective and timely communications will be (for example the charity may want to invite you to an
event by email or ask for feedback about aspects of its work by telephone). You can change these choices or opt not to receive any more communications at any time.
o post o telephone o email o text message
5. Payment details
o Payment by cheque
o I enclose a cheque made payable to Sue Ryder Lottery Limited (minimum payment £13)
o Direct Debit Name and full postal address of your Bank or Building Society.
Bank/Building Society
To the Manager of :
Address:
Postcode:
Name(s) of account holder(s):
Bank/Building Society
account number:
Branch Sort Code:
Please fill in the form and send to: Sue Ryder Lottery, Furness Gate, Furness Business Park, Barrow-in-Furness, Cumbria, LA14 2PE
Instruction to your bank orbuilding society to pay by Direct Debit
Service User Number:
2
6
1
0
3
1
Reference:
Instruction to your bank or building society Please pay Sue Ryder Lottery Limited Direct Debits from the account detailed in this
Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with
Sue Ryder Lottery LTD and, if so, details will be passed electronically to my bank /building society.
Signature:
For Sue Ryder use only:
WDL15
For office use only:
Sue Ryder is a charity registered in England and Wales (1052076) and in Scotland (SC039578).
Ref. No. 04494. ©Sue Ryder. September 2015.
Date:
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DD15