Complete the application form for Reach - The Association for Children with Hand or Arm Deficiency

To play simply complete all 3 sections and return your completed form to us at Lottery Service Providers Ltd, FREEPOST NEA12220, LEEDS LS6 2YY. Each entry costs £1 a week - that's just 20p a day
oneChoose 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 £4.34  
2 £8.68  
3 £13.02  
twoYour Details
Complete your personal details and sign below.
Name
Address
Postcode
Signature

 
threeHow to Pay  (You can pay by Cheque or Postal Order, or you can pay by Bank Standing Order)

To pay by Cheque or Postal Order, make cheques payable to Prize Provision Services Ltd

£13 per line for 13 Weeks
£26 per line for 26 Weeks
£52 per line for 52 Weeks
To Pay by BANKERS STANDING ORDER, please complete the following:
to the Manager of:
Bank
Address
Postcode

 

Please pay Prize Provision Services Ltd A/C No. 22438844 Sort Code 40-27-15 the amount of:
£4.34 £8.68 £13.02 Monthly
(delete as applicable)
 
My Account Name
Account                
Sort Code     -     -    
Signature
Print Name
Start from (for office use only)
and thereafter until further notice quoting my membership number of
for office use only