Name:

Address:

Post Code:

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Signature:

Standing Order Mandate

Bank Name:

Address:

Town:

Post Code:

Pay the Royal Bank of Scotland, Airdrie, Sort Code 83-15-11 for the credit of
St. Andrew’s Hospice Lottery Account No 00614674

Number of Chances per Week:

Please deduct : £4.34 per chance: Total Deduction £
Per month commencing now and thereafter each calender month.

Please deduct : £13 per chance: Total Deduction £
Commencing now and thereafter every 13 weeks.

Please deduct : £26 per chance: Total Deduction £
Commencing now and thereafter every 26 weeks.

Please deduct : £52 per chance: Total Deduction £
Commencing now and thereafter every 52 weeks.

Until you receive further notice from me in writing

Account Name:

Account No:

Sort Code: ____/___/____

Signature:

Date:

Bank Use Only.

Surname:

Lottery Number