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BREK LOT 000 000

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									                                                                                                             BREK LOT 000 000




                  Change of Contact Details
                                              Notification
                           Small Society Lottery

Name of Society:                           ...........................................................................................


Registration Number:                       ...........................................................................................


Please detail changes to be made:

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Contact No:                                ...........................................................................................


Signature:                                 ...........................................................................................


Name:                                      ...........................................................................................


Date:                                      ...........................................................................................




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