Lotteries Application Form

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Gambling and Gaming Application Form

What is this application for?
- This application form is for customers to bring a claim against a gambling or
  gaming company.
- The application form will ask you for the details needed to help the adjudicator understand what you would like the company to do and how to decide your dispute.
What do I need to do?
- Read the Guidance for Customers and Scheme Rules carefully. If you are unsure of how to answer a question please contact CEDR for guidance.
- Fill in the application form giving as much information as you can.
- It may take you some time to go through the application form and get all your evidence together, but having all the information will help CEDR assess your case fairly.
You must have already complained to the company and given them time to address your concerns before referring the matter to CEDR.

Please let us know if you have any practical needs where we could help – for example with information in another format (e.g. larger print, another language, etc.). If you require assistance in completing this form please contact us.

PDF Application Form Available

If you require a printable version of the application form, to post to us, please click here. We can also send you a paper version, please email applications@cedr.com to arrange this.

If you would like to post your application in, please download the PDF application form above.

You can send applications to:
CEDR Services Ltd
100 St. Paul's Churchyard
London
EC4M 8BU

Gambling and Gaming Application Form
1. About you

Please provide your full contact details.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email*
example@example.com
Telephone

Area CodePhone Number
2. Representation
YesNo
If someone is applying on your behalf, please provide their details here and sign the declaration.
Name

First NameLast Name
Organisation
If applicable
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email
example@example.com
Telephone

Area CodePhone Number
To be signed by the applicant named in section 1. I hereby give my authority for the above named person to represent me:

Clear
Type your name

First NameLast Name
Date

DayMonthYear

3. Company details

Please provide the following details about the gambling or gaming company you are in dispute with.
Company name*
Account name
Your account number
4. Raising your concerns
GamblingGamingOther
Please specify:

0/500
Date you first complained to the company:*

DayMonthYear
Complaint reference number (if known):
Date you received a letter from the company entitled ‘Final Response’ (if received):

DayMonthYear
5. Your complaint
Please tell us what your complaint is about and why you are unhappy with the company. This information will be sent to the adjudicator assigned to your case so it is important that you provide clear information about the issues you have experienced.

Please send us any documents that support your claim, such as your correspondence with the company and receipts for anything that you have purchased. You may submit any evidence you wish.

You may wish to include:
- Bills and/ or statements
- Correspondence to and from the company
- Photographs and videos
- Receipts
- Recordings (audio)
Transaction description
Please tell us what transaction or transactions this dispute relates to*

0/1000
Issues in dispute
Please explain the nature of the issues that have led to this dispute*

0/1000
6. What compensation are you requesting?
You must specify the total amount claimed in this section. There is no limit to the
amount you can claim but the adjudicator can only direct the company to pay proven claims up to £10,000. All claims in excess of £10,000 are subject to a non-binding recommendation that both the customer and the company must voluntarily agree to accept before it becomes binding.

You must provide evidence to justify the amount claimed and you cannot change the amount at a later date. If the adjudicator issues a direction or recommendation in your favour, they could direct or recommend any amount of money up to the total amount you have claimed. Please read the Scheme Rules for a full explanation of the adjudicator’s powers.
Total claimed:
£
Please attach any supporting evidence.

Limit: 10 files
Cancelof

7. Declarations
Data Protection Act
By signing this application you are providing your consent for the company to provide information and documentation about you to CEDR.

For more information on our privacy practices and commitment to protecting your privacy, please view our Privacy Policy.
I have tried to resolve this matter through the company’s complaints procedure.I am applying to CEDR to appoint an adjudicator to settle my dispute in accordance with the Scheme Rules.I have read and understood the guidance provided in this application form and on the CEDR website.I have not previously referred this dispute to a court of law.
Signature*

Clear
Type your name*

First NameLast Name
Date*

DayMonthYear

The companyCitizens AdviceGambling CommissionMoney Saving ExpertTwitterOther
We are working on improving our application process, please give a rating on your experience of completing this form.
Please verify that you are human*
Should be Empty:

Gambling and Gaming Application Form

What is this application for?

What do I need to do?

You must have already complained to the company and given them time to address your concerns before referring the matter to CEDR.

PDF Application Form Available

Gambling and Gaming Application Form

1. About you

2. Representation

3. Company details

4. Raising your concerns

5. Your complaint

Transaction description

Issues in dispute

6. What compensation are you requesting?

7. Declarations