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PRIZE CLAIM FORM OVER £20 PAID BY CHEQUE

GREENWICH & BEXLEY COMMUNITY HOSPICE

BE A STAR SUPPORT OUR NURSES – SCRATCH CARDS

· Print your name, address, phone number on back of ticket and sign your name

· Complete items 1 through to 10 on this form

· Staple ticket to bottom of form shown below

CLAIM INFORMATION

If not claiming in person,

MAIL AT OWN RISK TO:-

Freepost RTJU-GSSJ-KEAS

Greenwich & Bexley Community Hospice

185 BOSTALL HILL

LONDON

SE2 0GB

020 8320 5785

1. First Name: …………………………………………………………………………….……………..

Claimant’s Declaration:-

2. Surname: .……………………………………………………………………………………………….

I hereby claim payment for any prizes

3. Address: ……………………………………………………………………………………………..…..

……………………………………………………………………………………..……………………………………..

4. Town:………………………………………………………………………………………………………..

5. County: …………………………………………………………………………………………………..

6. Post Code: ………………………………………………………………………….………………..

7. Home/Mobile No: ……………………………………………………………………………..

associated with the attached scratch

card(s) and I declare that:

· To the best of my knowledge and

belief all of the information in this claim

is true and correct;

· I am over the age of 16 years; and

· I am the rightful owner of the

attached scratch card(s)

8. Date of Birth:

Day Month Year

I understand that:

· It is an offence under the Rules of

Authorised Lotteries to make a false or

misleading claim.

9. Prize Claimed:

£

……………………………………………………………………..

Claimants Signature:

……………………………………………………………………………….

10. Date:

…………………………………………………………………..

STAPLE

TICKET

HERE

FOR LOTTERY USE ONLY

Received by: ……………………………………………………………………………….……….…

Processed by: ……………………………………………………………………………………..…

Date: ………………………………………………………………………………………………………..…

Shop purchased from: ………………………………………………………………………

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