Title

DrMrMrsMissMsOther

Full name (including middle names)*

Job role

Directorate

Phone number

Work address

Payroll number*

Email*

Employed by (please tick):

York Teaching Hospital NHS Foundation Trust

York Teaching Hospital NHS FT LLP (Facilities Management)

Please tick here if you are bank staff ONLY

If you are bank staff you will need to set up a standing order to take payment for you lottery. Payroll will send you the necessary details.

Part A

I am not a member of the lottery but I want to join

Please select the amount of numbers you'd like on the lottery (£2 per number per month)

12345678910

Part B

I am already a member of the lottery but want extra numbers

Number of numbers already held

Number of additional numbers required (not including already held)

Declaration

I authorise the deduction of lottery entry fees from my salary with effect from the month prior to my number(s) being entered into the draw following receipt of this form by the lottery office, until cancelled by me in writing or until the termination of my employment with York Teaching Hospital NHS Foundation Trust or LLP. I acknowledge that I have read and understand the York Teaching Hospitals Foundation Trust staff lottery rules.*

Please note: The Finance Department deals with lottery applications on the 8th of every month. You will receive a confirmation letter with your lottery numbers and staff card shortly after this date.