Get documents about "Personal Details of Subscriber Subscriber No
Document Sample
MAIL SUBSCRIPTION SERVICES APPLICATION FORM
Personal Details of Subscriber:
Subscriber No:
Game: Lotto PowerBall ( This form caters for both Games)
Title: Ms Mr Mrs Other:
First Name: Surname:
ID Number:* *Non RSA citizens may use a passport number
Residential Address:
City:
Province: Postal Code:
(If not the same as above)
Postal Address:
City:
Province: Postal Code:
Tel No (W): Tel No (H):
Cell No: Fax No:
Email:
Date of Birth: (dd/mm/yyyy)
Your winnings will be paid directly via EFT into your bank account:
Account Holder Name: Chq Savings
Name of Bank:
Branch Name:
Account Number:
Branch Code:
( Please note : if payment by cheque is required please contact the Gidani Offices on 011 564 0000)
Communication and Marketing Permission
I agree to receive notices, promotional or other material, via either email, SMS, fax or regular mail.
Preferred medium of communication: Email SMS Post Fax
Declaration:
I have read all the information and agree to abide by all the applicable game rules.
I am aged 18 years or older. I am a resident of South Africa. The information that I have given is accurate and true. I
have completed the direct debit order section / enclosed a cheque / proof of eft payment or postal order for the correct
amount. I have attached a copy of my ID to the subscription form.
Signed: _______________________________________________________________
( Please note : If a form is unsigned it will NOT be accepted)
Gifts Subscriptions: You can now give someone the gift to Tata Ma Millions®
(Complete this section for gifts only)
Details of Recipient:
Title: Ms Mr Mrs Other:
First Name: Surname:
ID Number:* *Non RSA citizens may use a passport number.
Residential Address:
City:
Province: Postal Code:
(If not the same as above)
Postal Address:
City:
Province: Postal Code:
Tel No (W): Tel No(H):
Cell No: Fax No:
Email:
Date of Birth: (dd/mm/yyyy)
Your Gift Subscription winnings will be paid directly via EFT into nominated bank account:
Account Holder Name: Chq Savings
Name of Bank:
Branch Name:
Account Number:
Branch Code:
( Please note : if payment by cheque is required please contact the Gidani Offices on 011 564 0000)
Message that you would like to send (no more than 150 characters - including spacing)
Method of Payment
CHEQUE / POSTAL ORDER
Please note: Only cheques from a South African Bank account will be accepted. Cheques must be made
out to Gidani (Pty) Ltd. The cheque must be crossed "not transferable" with the words "or bearer"
deleted. It is also advisable to write your ID number at the back of the cheque.
Please find enclosed Cheque or Postal Order or Proof of EFT
for the sum of R
Gidani Mail Subscription Bank Account Details
Bank ABSA
Account Name: MAIL SUBSCRIPTIONS ACCOUNT
Cheque Account No: 4067959266
Branch: Sandton Business Centre
Branch Code: 632005
Please use your identity number on all EFT payments as a reference.
DIRECT DEBIT ORDER (we will debit your account for the applicable amount)
Please note: Your bank account should support a debit order facility
Account Holder Name: Chq Savings
Name of Bank:
Branch Name:
Account Number:
Branch Code:
Amount to be debited: R
I hereby “instruct and authorise Gidani (Pty) Ltd to draw against my account with the abovementioned bank (or any other bank or branch
to which I may transfer my account), the amount necessary for payment of the weekly / monthly premium due in respect of the
abovementioned agreement”. The required weekly / monthly amount shall be drawn on such day / days of each and every week / month as
Gidani (Pty) Ltd shall determine, commencing on the date of this agreement and continuing until termination of our agreement or until
cancelled by me in writing giving thirty (30) days notice and within the boundaries of our agreement. I agree that all direct debit payments
will be collected from my bank account in advance and that all such withdrawals from my bank account by you, shall be treated as though
they had been signed by me personally. I understand that the withdrawals hereby authorised will be processed through a computerised
system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement or
on an accompanying voucher. I agree to pay any bank charges relating to this debit order instruction. I understand that if my debit order is
not honoured more than three (3) times Gidani may refuse my participation via the debit option. This authority may be cancelled by me
giving Gidani thirty (30) days notice in writing, sent by prepaid registered post, but I understand that I shall not be entitled to any refund of
amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you. Receipt of this instruction
by you shall be regarded as receipt thereof by my bank (whichever it is or will be).
Assignment: I acknowledge that the party hereby authorised to effect the drawing(s) against my account may not cede or assign any
of its rights to any third party without my prior written consent and that I may not delegate any of my obligations in terms of this
contract / authority to any third party without prior written consent of the authorised party. I understand and accept that my numbers
will only be entered into any draw once payment has been received and my Subscription Certificate has been issued. I also confirm that
I have read the game rules applicable to the game or draw I have entered, as well as the rules applicable to this subscription and
that I understand and acknowledge them.
Please debit my account: (please mark with an X) Until I cancel For a specific amount of draws
Preferred Date of Debit to run: 1st 15th
Please select your preferred date of debit order to run and note that your debit order will run on the first business day after that
selected date (14 days waiting period before entry). Entry into the National Lottery will be on the date specified on your
Subscription Certificate.
Signature: ____________________________________
Date:
Select Your Lotto Numbers: 6/49
Board 1 1 Board 51 51
Board 2 2 Board 52 52
Board 3 3 Board 53 53
Board 4 4 Board 54 54
Board 5 5 Board 55 55
Board 6 6 Board 56 56
Board 7 7 Board 57 57
Board 8 8 Board 58 58
Board 9 9 Board 59 59
Board 10 10 Board 60 60
Board 11 11 Board 61 61
Board 12 12 Board 62 62
Board 13 13 Board 63 63
Board 14 14 Board 64 64
Board 15 15 Board 65 65
Board 16 16 Board 66 66
Board 17 17 Board 67 67
Board 18 18 Board 68 68
Board 19 19 Board 69 69
Board 20 20 Board 70 70
Board 21 21 Board 71 71
Board 22 22 Board 72 72
Board 23 23 Board 73 73
Board 24 24 Board 74 74
Board 25 25 Board 75 75
Board 26 26 Board 76 76
Board 27 27 Board 77 77
Board 28 28 Board 78 78
Board 29 29 Board 79 79
Board 30 30 Board 80 80
Board 31 31 Board 81 81
Board 32 32 Board 82 82
Board 33 33 Board 83 83
Board 34 34 Board 84 84
Board 35 35 Board 85 85
Board 36 36 Board 86 86
Board 37 37 Board 87 87
Board 38 38 Board 88 88
Board 39 39 Board 89 89
Board 40 40 Board 90 90
Board 41 41 Board 91 91
Board 42 42 Board 92 92
Board 43 43 Board 93 93
Board 44 44 Board 94 94
Board 45 45 Board 95 95
Board 46 46 Board 96 96
Board 47 47 Board 97 97
Board 48 48 Board 98 98
Board 49 49 Board 99 99
Board 50 50 Board 100 100
LOTTO PLUS®: Yes No
Select Your Lotto Numbers (Continued): 6/49
* Fill in six numbers from 1 to 49 in each board (one number per box)
* Subscribe for a period of 26, 32 , 52 or 104 draws
* Each board you choose will cost you R3.50 for each draw entered
* For a specific amount of draws we will debit your account once off for the applicable amount
* Entry into LOTTO PLUS® game will cost an additional R1.50 per board, making the total cost R5.00 per board
* Your selected numbers remain the same for the duration of your subscription
* Your LOTTO® number selection is automatically entered into the LOTTO PLUS® game draw
* Please see amounts due as per Table A or Table B
TABLE A Select a set amount of boards to play by placing a X over the relevant box
26 Draw 26 Draw incl. 32 Draw 32 Draw incl. 52 Draw 52 Draw incl. 104 Draw 104 Draw incl.
Number of LOTTO® only LOTTO PLUS® LOTTO® only LOTTO PLUS® LOTTO® only LOTTO PLUS® LOTTO® only LOTTO PLUS®
boards Amount Amount Amount Amount Amount Amount Amount Amount
1 R 91.00 R 130.00 R 112.00 R 160.00 R 182.00 R 260.00 R 364.00 R 520.00
2 R 182.00 R 260.00 R 224.00 R 320.00 R 364.00 R 520.00 R 728.00 R 1,040.00
3 R 273.00 R 390.00 R 336.00 R 480.00 R 546.00 R 780.00 R 1,092.00 R 1,560.00
4 R 364.00 R 520.00 R 448.00 R 640.00 R 728.00 R 1,040.00 R 1,456.00 R 2,080.00
5 R 455.00 R 650.00 R 560.00 R 800.00 R 910.00 R 1,300.00 R 1,820.00 R 2,600.00
6 R 546.00 R 780.00 R 672.00 R 960.00 R 1,092.00 R 1,560.00 R 2,184.00 R 3,120.00
7 R 637.00 R 910.00 R 784.00 R 1,120.00 R 1,274.00 R 1,820.00 R 2,548.00 R 3,640.00
8 R 728.00 R 1,040.00 R 896.00 R 1,280.00 R 1,456.00 R 2,080.00 R 2,912.00 R 4,160.00
9 R 819.00 R 1,170.00 R 1,008.00 R 1,440.00 R 1,638.00 R 2,340.00 R 3,276.00 R 4,680.00
10 R 910.00 R 1,300.00 R 1,120.00 R 1,600.00 R 1,820.00 R 2,600.00 R 3,640.00 R 5,200.00
11 R 1,001.00 R 1,430.00 R 1,232.00 R 1,760.00 R 2,002.00 R 2,860.00 R 4,004.00 R 5,720.00
12 R 1,092.00 R 1,560.00 R 1,344.00 R 1,920.00 R 2,184.00 R 3,120.00 R 4,368.00 R 6,240.00
13 R 1,183.00 R 1,690.00 R 1,456.00 R 2,080.00 R 2,366.00 R 3,380.00 R 4,732.00 R 6,760.00
14 R 1,274.00 R 1,820.00 R 1,568.00 R 2,240.00 R 2,548.00 R 3,640.00 R 5,096.00 R 7,280.00
15 R 1,365.00 R 1,950.00 R 1,680.00 R 2,400.00 R 2,730.00 R 3,900.00 R 5,460.00 R 7,800.00
16 R 1,456.00 R 2,080.00 R 1,792.00 R 2,560.00 R 2,912.00 R 4,160.00 R 5,824.00 R 8,320.00
17 R 1,547.00 R 2,210.00 R 1,904.00 R 2,720.00 R 3,094.00 R 4,420.00 R 6,188.00 R 8,840.00
18 R 1,638.00 R 2,340.00 R 2,016.00 R 2,880.00 R 3,276.00 R 4,680.00 R 6,552.00 R 9,360.00
19 R 1,729.00 R 2,470.00 R 2,128.00 R 3,040.00 R 3,458.00 R 4,940.00 R 6,916.00 R 9,880.00
20 R 1,820.00 R 2,600.00 R 2,240.00 R 3,200.00 R 3,640.00 R 5,200.00 R 7,280.00 R 10,400.00
Select Your PowerBall Numbers: 5/45 and 1/20
Board 1 1 Board 51 51
Board 2 2 Board 52 52
Board 3 3 Board 53 53
Board 4 4 Board 54 54
Board 5 5 Board 55 55
Board 6 6 Board 56 56
Board 7 7 Board 57 57
Board 8 8 Board 58 58
Board 9 9 Board 59 59
Board 10 10 Board 60 60
Board 11 11 Board 61 61
Board 12 12 Board 62 62
Board 13 13 Board 63 63
Board 14 14 Board 64 64
Board 15 15 Board 65 65
Board 16 16 Board 66 66
Board 17 17 Board 67 67
Board 18 18 Board 68 68
Board 19 19 Board 69 69
Board 20 20 Board 70 70
Board 21 21 Board 71 71
Board 22 22 Board 72 72
Board 23 23 Board 73 73
Board 24 24 Board 74 74
Board 25 25 Board 75 75
Board 26 26 Board 76 76
Board 27 27 Board 77 77
Board 28 28 Board 78 78
Board 29 29 Board 79 79
Board 30 30 Board 80 80
Board 31 31 Board 81 81
Board 32 32 Board 82 82
Board 33 33 Board 83 83
Board 34 34 Board 84 84
Board 35 35 Board 85 85
Board 36 36 Board 86 86
Board 37 37 Board 87 87
Board 38 38 Board 88 88
Board 39 39 Board 89 89
Board 40 40 Board 90 90
Board 41 41 Board 91 91
Board 42 42 Board 92 92
Board 43 43 Board 93 93
Board 44 44 Board 94 94
Board 45 45 Board 95 95
Board 46 46 Board 96 96
Board 47 47 Board 97 97
Board 48 48 Board 98 98
Board 49 49 Board 99 99
Board 50 50 Board 100 100
Select Your PowerBall Numbers (Continued): 5/45 and 1/20
* In each board, fill in five numbers from 1 to 45 and one PowerBall number from 1 to 20.
* Subscribe for a period of 26, 32 , 52 or 104 draws
* Each board you choose will cost you R3.50 for each draw entered
* For a specific amount of draws we will debit your account once off for the applicable amount
* Your selected numbers remain the same for the duration of your subscription
* Please see amounts due as per Table C or Table D
TABLE C Select a set amount of boards to play by placing a X over the relevant box
26 Draw 32 Draw 52 Draw 104 Draw
Number of PowerBall® PowerBall® PowerBall® PowerBall®
boards Amount Amount Amount Amount
1 R 91.00 R 112.00 R 182.00 R 364.00
2 R 182.00 R 224.00 R 364.00 R 728.00
3 R 273.00 R 336.00 R 546.00 R 1,092.00
4 R 364.00 R 448.00 R 728.00 R 1,456.00
5 R 455.00 R 560.00 R 910.00 R 1,820.00
6 R 546.00 R 672.00 R 1,092.00 R 2,184.00
7 R 637.00 R 784.00 R 1,274.00 R 2,548.00
8 R 728.00 R 896.00 R 1,456.00 R 2,912.00
9 R 819.00 R 1,008.00 R 1,638.00 R 3,276.00
10 R 910.00 R 1,120.00 R 1,820.00 R 3,640.00
11 R 1,001.00 R 1,232.00 R 2,002.00 R 4,004.00
12 R 1,092.00 R 1,344.00 R 2,184.00 R 4,368.00
13 R 1,183.00 R 1,456.00 R 2,366.00 R 4,732.00
14 R 1,274.00 R 1,568.00 R 2,548.00 R 5,096.00
15 R 1,365.00 R 1,680.00 R 2,730.00 R 5,460.00
16 R 1,456.00 R 1,792.00 R 2,912.00 R 5,824.00
17 R 1,547.00 R 1,904.00 R 3,094.00 R 6,188.00
18 R 1,638.00 R 2,016.00 R 3,276.00 R 6,552.00
19 R 1,729.00 R 2,128.00 R 3,458.00 R 6,916.00
20 R 1,820.00 R 2,240.00 R 3,640.00 R 7,280.00
TABLE D Monthly Debit Order - select an option by placing a X over the relevant box
Number of Draw Number of Draw Draw
boards Amount Boards Amount Number of Amount
played PowerBall® played PowerBall® Boards played PowerBall®
1 R 3.50 13 R 45.50 25 R 87.50
2 R 7.00 14 R 49.00 26 R 91.00
3 R 10.50 15 R 52.50 27 R 94.50
4 R 14.00 16 R 56.00 28 R 98.00
5 R 17.50 17 R 59.50 29 R 101.50
6 R 21.00 18 R 63.00 30 R 105.00
7 R 24.50 19 R 66.50 35 R 122.50
8 R 28.00 20 R 70.00 40 R 140.00
9 R 31.50 21 R 73.50 45 R 157.50
10 R 35.00 22 R 77.00 50 R 175.00
11 R 38.50 23 R 80.50 55 R 192.50
12 R 42.00 24 R 84.00 60 R 210.00
Please Note
The original of this application must be posted to Private Bag X129, Halfway House, 1685
Please mark FOR ATTENTION: MAIL SUBSCRIPTION SERVICES
NB! A copy of the front page of your ID book MUST be attached
In order to get the subscription captured quicker you can fax back to 086 513 3910
Alternatively, you can e-mail the application to mailsubscription@gidani.co.za
Related docs
