Thank you for your interest in the HRFC 100 Club. In order for us to process your application, we would be grateful if you could complete this short form which will enable us to add you to the monthly draw, assign you a membership number and claim your monthly contribution to the lottery.

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* 1. Please give us your full name

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* 2. What is your address?

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* 3. What is your primary phone number?

From numbers 1-100, what membership number would you prefer?

(Please note that where the chosen numbers are already taken, you will be given the closest available entry to your first choice)

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* 4. First choice:

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* 5. Second choice

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* 6. Third choice

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* 7. Please type your name into the box below to confirm that you are happy for HRFC to use this information in order to process your application and issue a Direct Debit mandate to your bank for £8.00 per month.

The first payment will be taken within 5 working days of the application, and every month thereafter until cancelled by notification to HRFC.

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* 8. Please use the box below to provide the following information:

- Name of account holder (as displayed on card)
- Address of account holder
- Email address
- Bank account number
- Sort Code

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