Oldland Mill Trust "100" Club

Please complete this form and send it with your cheque payable to OLDLAND MILL TRUST to: John Pryse, Markham Rose, Theobalds Road, Burgess Hill, RH15 0SS I wish to join the draw with _____entries at £12 each per year Total Payment £_____ (Reduce by £1 for each draw missed.) Title: MR / MRS / MISS / MS / OTHER______________________ Name (in capitals please) ____________________________ Address____________________________________________ ___________________________________________________ Postcode ______________ Telephone___________________ email:________________________________________________ I understand that the first draw was on 12th July 2009 and will be on the first Thursday of each month thereafter until June 2010. Signed_________________________________Date__________