Lottery Gift Order Form - St Andrews Hospice

Lottery Gift Order Form

Step 1 of 5

Declarations

I confirm that I am aged 18 or over *

Yes, I am aged 18 or over

I confirm that the recipient of this Lottery gift is aged 18 or over *

Yes, the recipient of this Lottery gift is aged 18 or over

I confirm that I will pay for this gift using a Debit Card *

Yes, I will pay for this gift using a Debit Card

PLEASE NOTE: Due to gambling laws, we cannot accept Credit Card payments for this order

Your Details

Title

Your Name *

First

Last

Your Date of Birth *

Your Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Your E-mail Address *

Your Contact Telephone No. *

Recipient's Details

Title

Recipient's Name *

First

Last

Recipient's Date of Birth *

Recipient's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Recipient's Contact Telephone No. *

Message for the card?