Midlands Sporting Association Ltd, Molineux Stadium, Waterloo Road, Wolverhampton, WV1 4QR
Telephone:
01902 658 666
Email:
[email protected]
You must accept these terms and conditions before signing up, so please read them carefully -
Terms and conditions
Customer Ref:
Schedule
Service/Schedule:
Lottery - Goalden Gate - 1 Membership
Termination:
Until further notice
Payment Information
Payment Day:
1
15
January
February
March
April
May
June
July
August
September
October
November
December
2024
First Payment Date:
01 November 2024
I wish to pay a regular Direct Debit of:
£4.34
Personal Details
Title
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Mrs
Mr
Miss
Ms
Dr
Sir
Lord
Lady
Prof.
Rev.
Master
Mx
---Other---
First name
Surname
Date of birth
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Line2
Line3
Line4
Post code
Home phone number
Mobile phone number
Work phone number
Email
Additional Information
Can we contact you by Email?:
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Yes
No
Can we contact you by Mail?:
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Yes
No
Can we contact you by Phone?:
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Yes
No
Can we contact you by Text?:
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Yes
No
Do you agree to the terms and conditions? (You can review them at the top of the page):
---Select---
Yes
Instruction to your Bank or Building Society to pay by Direct Debit
APS Re Wolves Lottery, 34 Waterloo Road, Wolverhampton, WV1 4DG
Service User Number:
Account holder name
Account number
Bank sort code
Please tick to confirm you are the only person required to sign for this account
Checking the box indicates that I am the Bank/Building Society holder and no authority other than my own is required. If more than one person is required to authorise debits from the account, you are unable to setup a direct debit online.