Parent/Guardian to Sign If Applicant Is Under 16 Years of Age

Applicant’s Name:
Address:
Post Code
Telephone No: / Mobile No:
Email Address:

(you will be notified of your issued number/winnings by phone or email and these details will also be displayed on the BSDB website)

Are you a BSDB Member?

Y / N

I would like to participate in The Billy Steel Dark Blues ‘59 Club Draw’ in accordance with the Rules of the draw and I agree to pay a monthly entry fee equivalent to the amount specified below to be paid by Standing Order* until cancelled by me by notice in writing.

*Please contact the Draw Administrator for The Billy Steel Dark Blues Bank Account details, or if you wish to make payment by alternative means.

Please specify how many entries you would like in the draw

(entry & numbers will be subject to availability)

Monthly Entry Fee (£4 for every entry requested above) = / £
Signature :

(Parent/Guardian to sign if applicant is under 16 years of age)

When the Form is completed you have the option of :

a) emailing the Form to the Draw Administrator at

b) Print off the Form and send to the Draw Administrator, Mark Snaith, 294 Broughty Ferry Road, Dundee, DD4 7NJ.

Any queries relating to this draw should be directed to Mark Snaith at the above email address / postal address.

Please do not mark below line - Official Club Use Only

Standing Order processed/Payment Received / Date
Month of entry into Draw
Number(s) allocated
Cash/Cheque received / Countersigned by
Copy of Rules Issued

______

Data Protection Act: Please note that information supplied will be held on our membership database. This will only be used in Conjunction with The Billy Steel Dark Blues DSC communications and activities. Information will not be passed to third parties.

BSDB59CLUBONLINEAPPFORM22062017