Complete the following application form for
Campbeltown Picture House
To play simply complete all 3 sections, print and return your form to us at:
Prize Logistics Ltd, Derby House Stud, Retford Rd, Mattersey, Doncaster, DN10 5HJ.
Each entry costs £1 a week
1. Choose Your Lucky Numbers
Enter a single digit number (0-9 inclusive) in each box. Match 3 or more numbers in sequence to win.
Location C I T I E S
Example 3 4 0 0 5 1
Entry 1
Entry 2
Entry 3
Mark one box below to show how many entries you wish to play. Each 6 number entry costs £4.34 for 1 month (equal to just 25p a day).
Entries Cost for 1 month Mark Here
1 £4.34
2 £8.68
3 £13.02
2. Your Details
Complete your personal details and sign below.
Title/Initials/Surname
Address
Postcode
Email
Telephone
Signature
 3. How to Pay  (You can pay by Cheque or Postal Order, or you can pay by Bank Standing Order)

To pay by Cheque or Postal Order, make cheques payable to Prize Provision Services Ltd

£13 per line for 13 Weeks
£26 per line for 26 Weeks
£52 per line for 52 Weeks
To Pay by BANKERS STANDING ORDER, please complete the following:
to the Manager of:
Bank
Address
Postcode

 

Please pay Prize Provision Services Ltd A/C No. 22438844 Sort Code 40-27-15 the amount of:
£4.34 £8.68 £13.02 Monthly
 
My Account Name
Account
Sort Code - -
Signature
Print Name
Start from (for office use only)
and thereafter until further notice quoting my membership number of
for office use only