Lucy’s Lotto Application Form

Please complete and return the form to the Wiltshire Blind Association, St Lucy’s,1 Commercial Road, Devizes SN10 1EH You will receive a confirmation letter that your membership has been accepted and be notified of your number/s – please ensure you fully complete the form below. Remember that minimum membership is for 12 months.(applicants must be over 18)

I wish to apply for membership of Lucy’s Lotto.

Start month …………………………………….

I require 1 number or………….. (enter the quantity of numbers)

at £24.00 per number for the year.

Name …………………………………………………………………………..

Address ………………………………………………………………..

………………………………………………………………..

Postcode ………………………………………...............

Phone …………………………………………………

Email (if applicable) ……………………………………..

I have enclosed a cheque or postal order for £………………………

Or I have completed the standing order mandate (overleaf)to the value

of £ ………………………………..

Signed ………………………………………………….

Office Use

Reference number : …………………………………………………………………………...

Allocated Lotto Numbers: …………………………………………………………………….