Eden Hospice Valley, Durdar Road, Carlisle, CA2 4SD
Telephone:
01228 810801
Email:
[email protected]
Customer ref:
Schedule
Service/Schedule:
A. Lottery - 1 Chance - Monthly
A. Lottery - 1 Chance - Monthly - 'Keep the Change'
A. Lottery - 2 Chances - Monthly
A. Lottery - 3 Chances - Monthly
A. Lottery - 4 Chances - Monthly
A. Lottery - Monthly - Adhoc
B. Lottery - 1 Chance - Quarterly
B. Lottery - 1 Chance - Quarterly - 'Keep the Change'
B. Lottery - 2 Chances - Quarterly
B. Lottery - 3 Chances - Quarterly
B. Lottery - 4 Chances - Quarterly
B. Lottery - Quarterly - Adhoc
C. Lottery - 1 Chance - Bi-Annually
C. Lottery - 1 Chance - Bi-Annually - 'Keep the Change'
C. Lottery - 2 Chances - Bi-Annually
C. Lottery - 3 Chances - Bi-Annually
C. Lottery - 4 Chances - Bi-Annually
C. Lottery - Bi-Annual - Adhoc
D. Lottery - 1 Chance - Annually
D. Lottery - 1 Chance - Annually - 'Keep the Change'
D. Lottery - 3 Chances - Annually
D. Lottery - 4 Chances - Annually
D. Lottery - Annual - Adhoc
Termination:
Until further notice
Payment Information
Payment Day:
1
8
15
23
January
February
March
April
May
June
July
August
September
October
November
December
2026
First Payment Date:
23 October 2026
I wish to pay a regular Direct Debit of:
£
8.68
Personal Details
Title
---Select---
Mrs
Mr
Miss
Ms
Dr
Sir
Lord
Lady
Prof.
Rev.
Master
Mx
Other
First name
Surname
Date of birth
Line1
Line2
Line3
Line4
Post code
Home phone number
Mobile phone number
Work phone number
Email
Additional Information
1. I confirm that I am over 18 years of Age:
---Select---
Yes
No
2. What prompted you to play lottery?:
---Select---
Social Media
Newsletter
To Support the Hospice
Friend / Family
Website
For Office Use Only C1
Other
3. Would you like to receive our Newsletter?:
---Select---
Yes - by post
Yes - by email
Yes - by phone
No thanks!
4. Would you like to hear about our Events and Appeals?:
---Select---
Yes - by post
Yes - by email
Yes - by phone
No thanks!
5. Would you like to receive our Raffle Tickets?:
---Select---
Yes - by post
Yes - by email
Yes - by phone
No thanks!
6. Would you like information about our Hospice Shops?:
---Select---
Yes - by post
Yes - by email
Yes - by phone
No thanks!
7. Would you like details about Volunteering at the Hospice?:
---Select---
Yes - by post
Yes - by email
Yes - by phone
No thanks!
8. Lottery Number (if already a player):
I confirm that I am over 18 years of age::
---Select---
Yes
No
Lottery number (if already a player)::
What prompted you to play the lottery?:
---Select---
Social Media
Newsletter
To Support the Hospice
Friend / Family
Website
For Office Use Only C1
Other
Would you like to hear about hospice news via email?:
---Select---
Yes
No
Would you like to hear about how to support the hospice via email?:
---Select---
Yes
No
Would you like to hear about lottery/raffle updates via email?:
---Select---
Yes
No
Instruction to your Bank or Building Society to pay by Direct Debit
Eden Valley Hospiceshop Ltd, Durdar Road, Carlisle, CA2 4SD
Service User Number:
Custom Bank Reference:
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.
Please download PDF version of direct debit instructions by clicking on the button below.
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