Lottery Ticket
Order Form
Vehicle generously
donated by:
Your chance to win a 2015 Cadillac SRX!
Grand Prize Draw for 2015 Cadillac SRX on April 22, 2015 at
West Park Healthcare Centre
First Name:
Fax:
Phone:
416-243-8523
416-243-3663
Email: [email protected]
Last Name:
Address:
City:
Province:
Phone: Home (
)
ON
Postal Code:
Cell: (
)
I am at least 18 years of age
Email:
I am purchasing tickets in the Province of Ontario
Please send me:
set(s) of 5 tickets for $100 =
ticket(s) at $25 each =
$
$
I am enclosing a charitable donation of =
(Tax receipts can only be issued for donations over $20)
$
Total =
$
This is a gift. Please issue in recipient’s name. (Recipient must be at least 18 years of age)
Recipient’s Name:
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Please charge my:
VISA
MasterCard
Amex
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Exp: (mm/yy)
Lottery Licence #M765800. A total of 7,500 tickets will be printed for the West Park Lottery. By purchasing tickets, the purchaser
acknowledges that they have read and understand the rules and regulations. Charitable Registration # 11929 5350 RR0001