Complete the following application form for Blackheath RFC and post it to:
Lottery Service Providers Ltd
24 St. Michaels Road, Headingley, LEEDS LS6 3AW

To play simply complete all 3 sections and return your completed form to us at Lottery Service Providers Ltd, 24 St. Michaels Road, Headingley, LEEDS LS6 3AW. Each entry costs £1 a week - that's just 20p a day

1. Choose Your Lucky Numbers

Enter a single digit number (0-9 inclusive) in each box. Match 3 or more numbers in sequence to win.
Location C I T I E S
Example 3 4 0 0 5 1
Entry 1            
Entry 2            
Entry 3            

Tick one box below to show how many entries you wish to play. Each 6 number entry costs £4.34 for 1 month (equal to just 20p a day).
Entries Cost for 1 month Tick Here
1 £4.43  
2 £8.68  
3 £13.02  
2. Your Details

Complete your personal details and sign below.
 
Name
Address
Postcode
Signature

3. How to Pay
Please complete the following

BANKERS STANDING ORDER

to the Manager of
Bank
Address
Postcode

Please pay The Great Numbers Game A/C No. 22438844 Sort Code 40-27-15 the amount of
£4.34 £8.68 £13.02

Monthly
My Account Name
Account                
SortCode    

-

    

-

    
Signature
Print Name
Start from (for office use only)

and thereafter until further notice quoting my membership number of
for office use only