MEGA MILLIONS SUBSCRIPTION APPLICATION North Dakota Lottery
NORTH DAKOTA ATTORNEY GENERAL 1050 E Interstate Ave - Suite 200
LOTTERY DIVISION Bismarck ND 58503-5574
SFN 59683 (11/10) Phone: (701) 328-1574
Select either A (Mega Millions only) or B (Mega Millions with Megaplier) below.
A. Select the number of draws you want to play:
26 Draws - $24 52 Draws - $47 104 Draws - $94
OR
B. Win up to $1 Million with Megaplier! - For an extra $1 per play you can multiply your winnings (except jackpot and Match 5 prize
levels) 2 to 4 times. The Match 5 prize with Megaplier will always be a $1 Million prize regardless of the Megaplier number. Select option
below to choose Mega Millions/Megaplier:
26 Draws - $47 52 Draws - $94 104 Draws - $188
Subscriber Number Subscription Number
Is this a renewal? Yes No
Full Name (one name only) Date of Birth (required)
Address
City State ZIP Code
ND*
Day Telephone Number Alternate Telephone Number
E-Mail address (optional)
A Gift From (optional) Telephone Number
I attest that the date of birth on this application is correct. (Must be 18 years of age or older.)
Signature
Payment via
Check Credit/Debit Card Money Order Other
(The Lottery is not responsible for payment lost in the mail.)
Visa MasterCard Discover
Card Account Number Exp. Date Amount Security Code (3-digit number on back of card)
Cardholder's Name
Cardholder's Address
City State ZIP Code
Day Telephone Number Alternate Telephone Number
Signature
How to play
Select Quick Pick or fill in (darken)
5 of the 56 numbers (white balls): and 1 of the 46 numbers (Megaball):
Quick Pick Quick Pick
*North Dakota mailing address required. Allow 3 to 4 weeks for processing.
Subscription valid for dates on Lottery confirmation card.