Registration

Eden Hospice Valley, Durdar, Carlisle, CA2 4SD

Telephone: 01228 810801 Email: [email protected]

Customer Ref:

Schedule

Service/Schedule:

Termination:

Until further notice

Payment Information

Payment Day:

2024

First Payment Date:

15 May 2024

I wish to pay a regular Direct Debit of:

£8.68

Personal Details

Title

First name

Surname

Date of birth

Line1

Line2

Line3

Line4

Post code

Home phone number

Mobile phone number

Work phone number

Additional Information


1. I confirm that I am over 18 years of Age: *
2. What prompted you to play lottery?: *
3. Would you like to receive our Newsletter?: *
4. Would you like to hear about our Events and Appeals?: *
5. Would you like to receive our Raffle Tickets?: *
6. Would you like information about our Hospice Shops?: *
7. Would you like details about Volunteering at the Hospice?: *
8. Lottery Number (if already a player): *

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.