Terre Sans Frontières Mercedes Raffle
The draw will be held on April 29, 2010, at 4 pm
This raffle is limited to the Province of Quebec only
This form is for mail or fax ordering
You can buy tickets individually or form a group
Fill, print, sign and mail or fax to :
399, des Conseillers Street
La Prairie Qc J5R 4H6
Fax : 450-659-2276
For phone ordering please call 1 877 873-2433
First Name
Name :
Address :
City :
Province :
Postal Code :
Home Phone :
Other Phone :
Email :
I'm buying :
ticket(s) at $150 each
I'm buying :
TSF+ ticket(s) at $175 each
Amex
Mastercard
Visa
Card Number :
Expiry Date :
/
(month / year)
Name of card holder :
Sign_here:____________________________
Form a group !
Put the name of each participant and the amount of his/here share