Lottery Application Form

Please fill in your details, tick your preferred

Payment method and return to Katharine House

Hospice (address on previous page)

Full Name................................................................

Address...................................................................

...............................................................................

.........................................Postcode........................

Telephone No...........................................................

Method of Payment

Standing Order             Please complete mandate

Cheque Payment         Please enclose cheque for

                                       £13, £26 or £52 made

                                       payable to Katharine House

                                       Hospice

Credit/Debit Card        Please tick:

                                       £13 £26  £52

Please debit my:

 Visa   Delta    Mastercard   Switch

Name of Cardholder

(CAPS)...................................................................

Card No.  

Valid from........./......... Expiry date.........../...........

Security Code............................................

Issue No................Switch only

Signature..............................................................

Date.....................................................................

Standing Order Mandate

Please complete this section with details of your

own bank, only if paying by standing order.

Name of Your Bank/Building Society:

.................................................................................

Address.....................................................................

.................................................................................

..............................................Postcode.....................

PLEASE PAY

HSBC, 17 Market Place, Banbury, Oxon OX16 8ED

Sort Code: 40-09-02 Account No. 41470957

The Sum of: PLEASE TICK APPROPRIATE BOX

For ONE Chance                 For TWO Chances

per week                            per week

  £52 every 52 weeks            £104 every 52 weeks

  £26 every 26 weeks         £52 every 26 weeks                       

 £13 every 13 weeks         £26 every 13 weeks

First Payment to commence immediately.

Please complete this section with details of your

own account

Yours Account Name...........................................

Yours Account No...............................................

Sort Code...........................................................

Signature...........................................................

Please return to Katharine House Hospice(address on

previous page)