Ticket Order Form

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					              lottery 139
              WOF
                                   Ticket Order Form
1. I would like to order:
        400 Chances ($200)             150 Chances ($100)         70 Chances ($50)            40 Chances ($30)                 30 Chances ($25)
        20 Chances ($20)               10 Chances ($15)           6 Chances ($10)             3 Chances ($5)                   1 Chance ($2)

                                                                                     4. Payment Options:
2.          Yes, I would like to join the Champions’
            Club to receive tickets in every lottery                                    Please charge my:
            until further notice. ($10 minimum                                          Card Number:
            required. Credit Card/Direct Debit only)


3. Title:         First Name:                          Surname:                                                               Expiry Date:               /

     Address:                                                                           Cardholder’s Name: _________________________________________

                                                   State:         Postcode:             Signature: _________________________________________________

     Phone (h):                                                                         OR:            I enclose Cheque/Money Order for my tickets
                                                                                                  (Make payable to Surf Life Saving Foundation in $AU only)
     Phone (m):
                                                                                        OR:       To pay via Direct Debit please phone 1800 642 999 (Aust)
     Email:
                                                                                        For Office Use Only:   CHQ    MO     AX    DI    MC     VSA     C     DD

				
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posted:5/5/2010
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Description: Ticket Order Form