Health Lottery Syndicate Application

TO COMPLY WITH UK GAMING LAWS, ALL BOXES MUST BE FULLY AND ACCURATELY COMPLETED

Your Full Name:

Home Address:

Email Address:

Telephone No.
 (include STD code)
Mobile No.

Date of Birth:
 (for example - 31/08/1968)
Please click here for terms & conditions and full details of Membership.

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I wish to set up a Bank Standing Order and accept that my membership does 
not begin until the first payment has been received by HLS.   
(Note: Syndicate Manager will contact you.)

(if this button has been ticked, ignore next section and move on to enter numbers below).

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Number of Weeks Play:  (Minimum 13 Weeks)

Total: £  at £ 1.00 per week.

Cheque/Money Order Number:   (for your reference).
Do NOT send cash.

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I wish to use the following Numbers
for the duration of this current membership.

Main Numbers     
Main Numbers - choose any five between 1 and 50 (inclusive)

OR

I wish to have the "Syndicate & Fund Manager" select my numbers for me.    

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I the undersigned, have read and agree with the Health Lottery Syndicate 
Terms and Conditions in their entirety and shall abide by them accordingly.
 (enter YES) 
Failure to enter YES here invalidates your Syndicate Membership Application
and all monies will be returned to you (subject to the Administration Fee).

Now, please click here and print two copies of this page

(ensure you change your printer page setting to A4).

Signature:


Once printed, sign both copies keeping one for your records and post the
second copy to me with Syndicate Membership payment.
(See below for address and payment requirements).

Thank you for completing this application.

Subject to all of above being fully and accurately completed, you shall receive your
Membership Confirmation and Unique Registration Number as soon as practical.

Please make Cheque/Money Order payable to; Mr G W Gill
and send with this Application Form to;

HLS, C/o 57 Dalmatia Road, Southchurch, Southend-on-Sea,
Essex SS1 2QG, England UK

CONFIDENTIALITY PROMISE

ALL INFORMATION SUPPLIED TO;
NNE Health Lottery Syndicate and Geoffrey W Gill
WILL BE KEPT IN TOTAL CONFIDENCE AND WILL NOT BE PASSED ON
TO ANY THIRD PARTY UNLESS LEGALLY BOUND TO DO SO.