Portage District General Hospital Foundation
2017 Lottery
Official Ticket Request Form
Name:
Address:
City/Town:
Prov.
Telephone:
Alt Phone:
Email:
Method of Payment:
Cheque
Postal Code:
Money Order
Card Holder Name:
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Portage Hospital Lotto Tickets
50/50 Draw
50 50 draw tickets may only be purchased in conjunction with
Portage Hospital Lotto Tickets
Tickets @ $100.00 each
1 Ticket - $20.00
SOLD OUT Tickets @ 3 for $250
5 Tickets - $50.00
Total Amount for Lottery Tickets
Total Amount for 50/50 Tickets
$
Lottery License No. LGA 5620 RF
Tickets may only be purchased or sold within Manitoba.
Please make cheque payable to:
Portage Hospital Lotto
524 – 5th St SE, Portage la Prairie, MB R1N 3A8
Official Ticket(s) to follow. Please allow 2 - 3 weeks for delivery
Total Ticket Order