Gold Rush Name Change / Removal Form Please make the following change(s) to this Gold Rush number Change My Information (ie. phone, email, or address) Cancel My Number(s) Assign My Number to a New Owner Add a Name to my Ticket Remove a Name from my Ticket My Gold Rush number(Required) Current name on it(Required) First Last Phone(Required)Email(Required) Please provide reasoningNew Name: (if changing) First Last New Phone: (if changing)New Email: (if changing) Permission I give permission to have my name removed from GoldRush. I hereby give Big Brothers Big Sisters / Boys and Girls Club of Miramichi permission to *remove my name from the above mentioned Gold Rush ticket. This will also remove my claim to any future winnings that this number may be drawn for.Authorization I am acting on behalf of an immediate family number. This box must be checked if the individual completing this form is acting on behalf of an individual whose name is on the above stated Gold Rush number. The person “acting on behalf of” must be an immediate family member of the individual whose name and Gold Rush number is stated above. By signing below, indicates that the individual whose name is currently on the above listed Gold Rush number is aware and agrees to the following changes / removal.Name(Required) First Last Date(Required) MM slash DD slash YYYY Electronic Signature(Required) Reset signature Signature locked. Reset to sign again NameThis field is for validation purposes and should be left unchanged. Δ Gold Rush Gold RushHow to PlayUpdate Info/Make Change to your NumberPre Pay NumberCheck Your Prepaid NumberWinnersRulesFrequently Asked QuestionsLocationsVideo of Gold Rush Process
