Cancel your Number Please cancel my Gold Rush Number(s) My Gold Rush number(Required)Current name on it(Required) First Last Phone(Required)Email(Required) Please provide reasoningPermission 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 Number(s). 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 Removal of this Gold Rush Number.Date(Required) MM slash DD slash YYYY Electronic Signature(Required)CommentsThis field is for validation purposes and should be left unchanged.
