11/18/12 Postal registration f orm | The National Lottery

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Please send this form and identification to:The National LotteryFreepost ANG 9610WatfordHertfordshireWD18 9BR

Application number 669451513

Preferences:

I wish to receive information about:

Special offers, rollovers, new games and other exciting National Lottery events, products andservices

Products and services of Camelot's carefully selected business partners (whether from Camelot orthose business partners). In addition, I do not mind being contacted for Camelot's research

purposes

Terms and Conditions and Rules accepted

Terms and Conditions

Name Mr. Alireza Khalil BeigiKhameneh

Date of birth 8 Jun 1981

Home address Flat Apartment 1105X Q 7 Building Taylorson StreetSouthSALFORDM5 3FY

Gender Male

Home phone 07730589793

Email address alireza_khalilbeigi@yahoo.com Mobile phone 07730589793

Additional information for 16 to 19 year olds

Driver's Licence No.

Your last name at birth

Your mother's maiden name

11/18/12 Postal registration f orm | The National Lottery

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Utility bill (Gas, Electricity, Water, Council Tax) Telephone bill Mobile phone bill

Please provide one form of identification from the list below. Documents must be originals and nomore than 3 months old. I have enclosed the following as identification (tick one):

Now read the statement below, sign and date the form and return it to us at:The National Lottery, Freepost ANG 9610, Watford, Hertfordshire, WD18 9BR.

In registering your personal details on the National Lottery Site you confirm that you have read,accepted and agree to abide by the Interactive Account Terms and Conditions, Rules for InteractiveInstant Win Games and Rules for Draw-Based Games Played Interactively (which govern access to anduse of the Games). In addition, when you play a particular Game you agree to abide by any GameProcedures which apply to that Game and confirm your acceptance of the Privacy Policy.

SignedWe cannot accept

unsigned forms

Date

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