50:50 Lottery Application Form

Your First Name
Your Last Name
Your Address

Your Postcode
Your Phone
Your Email
Confirm Email

Please allocate me lottery numbers at £5 per number per month,
making a total of £ per month.

Please select one of the following payment options:

Standing Order
Cheque

You have selected to pay online. This will require a monthly payment of £

You have selected to pay by bank Standing Order. This will require a monthly payment of £
It is your responsibility to create this monthly standing order with your own bank.
Please pass on to your bank the following details of Reading Mencap's bank in order set this up.
Please do this via your online banking or in person at your bank branch.
Account name: Reading Mencap
Address: HSBC, 1-2 Market Place, Wokingham RG40 1AL
Sort code: 40-47-09
Account number: 91783009
Reference: Please use as the reference 50'your full name', eg 50JoeBloggs

You have selected to pay by cheque. This form of payment for the Reading Mencap 50:50 Lottery
requires the advance payment of a cheque for a full 12 months of lottery entries.
This will require a cheque for the sum of £ made payable to Reading Mencap and posted and addressed to
Marie-Claire Dillon, Reading Mencap, 21 Alexandra Road, Reading RG1 5PE.

I agree to the terms and conditions shown here: Reading Mencap 50:50 Rules,
AND I undertake to pay the cheque or set up the standing order as advised above without delay.

I understand that I have the right to cancel my standing order at any time.
IF I do so I undertake to inform Reading Mencap without delay.