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For Payment By Cheque

I enclose a cheque made payable to “Saint Michael's Hospice Lottery” for £_________.00

Number of entries required each week: _______________________

Please indicate payment category required by ticking appropriate box:

	Quarterly Payment of £13		Half-yearly Payment of £26
	Annual payment of £52		Other period minimum £5

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For Payment by Standing Order      Note: one form to be completed for each entry

Please complete this form and return it to: Saint Michael's Hospice Lottery,
FREEPOST LS2051, Harrogate HG2 7BR (do not return to your bank)

Bank Name _____________________________________________________________________

Address ________________________________________________________________________

___________________________________________________ Post Code__________________

Account Name __________________________________________________________________

Account Number ________________________________ Sort Code _______-_______-_______

Please pay Lloyds Bank(Account 00323305 Sort Code 30-93-91), Saint Michael's Hospice
Lottery Standing Order Account the sum of:

Quarterly Payment of £13

Half-yearly Payment of £26

Annual payment of £52

(Please tick appropriate box)

Until you receive further notice from me/us in writing.

Signature(s) ___________________________________________ Date ____________________