Preferred Start Date (if any).............................(You will be notified in writing, before the first payment is taken).

Name ...............................................................

Address ...........................................................

.........................................................................

....................... Postcode .................................

Tel....................................................................

Email ...............................................................

Instruction to your Bank or BuildingSociety to pay by Direct Debit

2 9 4 5 0 5

Service User Number

This is not part of the instruction to your Bank or Building Society.

Single Membership Double Membership (1 Ticket) (2 Tickets)

Please complete the whole form including this section

Instruction to your bank or building society.Please pay Cornwall Air Ambulance Trust, Direct Debits from the account detailed in this instruction, subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with

, and if so, details will be passed electronically to my Bank/Building Society.

Cornwall Air Ambulance Trust

Signature(s)

Date

Name(s) of Account Holder(s)

Bank/Building Society Account Number

Branch Sort Code

- -Name and full postal address of your Bank or Building Society

To the Manager

Bank/Building Society

Address

Postcode

MonthlyAn initial payment of£6.34 then £4.34 monthly

£13 every 13 weeks

£26 every 26 weeks

£52 every 52 weeks

Monthly

£26

£52

£104

An initial payment of£12.68 then £8.68 monthly

every 13 weeks

every 26 weeks

every 52 weeks

Please tick one box to select the payment type :-

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits·If there are any changes to the amount, date or frequency of your Direct Debit, Cornwall Air Ambulance Trust will notify you 10 working days ·in advance of your account being debited or as otherwise agreed. If you request to collect a payment, confirmation of the amount and date will be given to you at the time of the request

If an error is made in the payment of your Direct Debit by or your bank or building society you are entitled to a ·full and immediate refund from your bank or building society- If you receive a refund you are not entitled to, you must pay it back when asks you to.

You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please ·also notify us.

Cornwall Air Ambulance Trust

Cornwall Air Ambulance Trust

Cornwall Air Ambulance Trust

The Direct Debit Guarantee

For Office Use Only

Please fill in the whole form except the box marked ‘For Office Use Only’ using a ball point pen.

Cornwall Air Ambulance TrustTrevithick Downs

Newquay

Cornwall

TR8 4DY

Tel: 01637 222525

Service User’sReference

Welcome to Mission Maker

The Cornwall Air Ambulance Lottery

Thank you once again for your kind support and good luck!

Thank you for taking the time to download our lottery application form. Please

complete the direct debit mandate opposite and send it to the address above.

The Cornwall Air Ambulance protects the population and visitors of Cornwall

over 1,300 square miles of remote countryside, bustling towns, coastline and

islands. Flying around 800 missions every year, our crew bring advanced

emergency medical care to our patients in their moment of need.

It costs over £2.5 million every year to keep this vital service flying, and

despite being an essential emergency rescue service, Cornwall Air Ambulance

receives no direct government funding. It’s funded by people like you.

Every time you play our lottery, you're helping fund lifesaving emergency

rescue missions for people in Cornwall and the Isles of Scilly. Playing Cornwall

Air Ambulance's Mission Maker lottery gives you the chance to win our weekly

£1,000 jackpot! There's also a 2nd prize of £250, a 3rd prize of £150 and ten

consolation prizes of £10.

On receipt of your application form we will send you a welcome letter. The

letter will contain your unique lottery numbers and more information on the

lottery. The draw takes place every Friday and the weekly winners are sent

their prize cheques through the post, so there's no need to claim..

If you have any questions about your lottery membership, please do not

hesitate to contact us, on our dedicated lottery help line 01637 222525, or

visit our website www.cornwallairambulancetrust.org/lottery, where you can

also see the weekly results and terms and conditions for the draw.

Cornwall Air Ambulance TrustTrevithick Downs, Newquay, Cornwall, TR8 4DY

For Lottery Enquiries Please Call 01637 222525For All Other Enquiries Please Call 01637 889926

If you win, your name and the town where you live, will appear on our web site. Tick here to withhold these details.

Tick this box if you do not wish to receive mailings from us.

Please tick this box to confirm that you are 16 or over.