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					                                                                                              Card Holder Name: _____________________________________ Card Holder Signature ________________________________________________

                                                                                                                                                                                                                               q Visa
                                                                                                                                                                                                                               q MasterCard
                                                                                                                                                                                                                                              Method of Payment: q Cheque q Money Order
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Lorne
Please return this form with payment to: P Box 130, Swan Lake, MB R0G 2S0
Make cheques Payable to: L.M.H.F. Inc. Lotto or Lorne Memorial Health Foundation Inc. Lotto




                                                                                                                                                                                                                                                                                          Telephone: _______________________________________ Email: ___________________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                          City/Town: ____________________________________________________ Prov: ___________ Postal Code: _______________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Address: ________________________________________________________________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Name: ___________________________________________________________________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Number of Tickets

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 TICKET APPLICATION
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      LORNE MEMORIAL HEALTH FOUNDATION INC. LOTTO 2011
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               EARLY BIRD DRAWS: Deadline is March 19th, 2011 at 9 PM
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Draw date is March 20th, 2011 at 12 noon
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Draws #1 to #10 $500.00 Cash Each
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Draws #11 to #15 $1,000.00 Cash Each
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    FINAL DRAW: Deadline is April 16th, 2011 at 7 PM
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Draw date is April 16, 2011 at 10 PM



                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Memorial
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Winners choice of one of the following options




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          ___________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Option #1 - Retail Value $94,575.00 plus taxes
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              One - Elmers Grain Gart 850 bu
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     AND Three Westeel Hopper Bins (5904 Bushels),
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Three 21’ Comte Cones (809 Bushels)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   with setup and delivery within 60 Miles of Swan Lake                                    Health Foundation      Inc.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Option #2 Retail Value $100,199.00 plus taxes                                              LOTTO 2011

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          @$100.00 ea = __________________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Material for a 1472 sq ft Cottage with free delivery within 60 miles of
                                          .O.




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Swan Lake AND One 2011 Sea Doo 150 Speedster with Tower
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            and bimini top, a stereo and a trailer
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PROCEEDS TOWARDS THE
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Option #3 Retail Value $98,535.15 plus taxes
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             One 2011 Kingsport 26ft Travel Trailer (265BHS) fully equipped
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Lorne Wellness Centre
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           including large slideout room and fiberglass exterior AND Two 2011
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Sea-Doo GTS 4 Stroke 3 Seat PWC’s & a 2 Place PWC Trailer AND One
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          2011 Polaris Ranger RZR 800 EPS LE Including a Pure Polaris winch
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         AND One 2011 Harley Davidson FLSTC - Black (Heritage Classic) AND
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               One 2011 Harley Davidson XL883N - Black Demin (883 Iron)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Option #4 Retail Value $97,427.00 plus taxes
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         One 2011 Ford Fiesta SE 4 Door AND One 2011 Ford Escape XLT AWD
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 3.0L V6 AND One 2011 Ford F-150 Super Crew XLT 4X4
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Option #5
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      $100,000.00 CASH

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             LORNE MEMORIAL HEALTH FOUNDATION INC. LOTTO
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             RULES OF PLAY
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • All draws are open to all ticket holders. Each ticket is re-entered for each draw.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • Only 3,500 tickets will be printed and available for sale.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • Winners will be notified by phone or mail.
                                                                                                                                                                                                                                Date
                                                                                                                                                                                                                                Expiry




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • In the event a prize(s) remains unclaimed 60 days after the final draw, the prize(s) will
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           be retained by the Lorne Memorial Health Foundation Inc.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • All prizes are awarded with all taxes paid. Winners are responsible for pick up and/or
                                                                                                                                                                                                                                                         M




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           delivery of prizes unless otherwise specified.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • Grand prize option # 1 includes setup and delivery of the Westeel Hopper bins within
                                                                                                                                                                                                                                                         M




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           60 miles of Swan Lake, MB. The Elmers Grain cart is a specialty item that would be
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           custom ordered for the winner upon their choosing the prize package.
                                                                                                                                                                                                                                                         Y




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • Grand prize option # 2 includes delivery of the Cottage Material Package within 60




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              .00
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             00,000
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           miles of Swan Lake, MB.
                                                                                                                                                                                                                                                         Y




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           1
         Please allow 2 - 3 weeks for Delivery




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       $
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • Group Purchases permitted, however a maximum of four names will appear on the
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ticket(s). Group members must work out the details of payment and prize collection
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           among themselves. The lottery will play no role in settling any disputes relating to
                                                                                                                                                                                                                                                                                                                                Other_______________
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                                                                                                                                                                                                                                                                                                                                                                                                                   q
                                                                                                                                                                                                                                                                                                                                                                                                                   q
                                                                                                                                                                                                                                                                                                                                                                                                                   q
                                                                                                                                                                                                                                                                                                                                                                                                                   q
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     (Please Check)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          about the lottery?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          How did you find out
                                                                                                                   Lottery License# # MGCC 5154RF




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           group purchases. All prizes will be awarded in the name of the primary holder which
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           is the first name appearing on the ticket.
                       Official Ticket to follow




                                                                                                                                                                                                                                                                                                                                                                                                                       Ticket Outlet
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Television
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Radio
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Newspaper
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Brochure




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • If a cheque or credit card payment is refused for whatever reason, any ticket(s)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           associated with that payment would not be eligible to win a draw. When full payment,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           plus any charges is received, the ticket(s) will be re-entered for future draws.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   ALL DRAWS TO TAKE PLACE AT:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       www.lmhflotto.com
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              SWAN LAKE COMMUNITY CENTRE
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           7 - 4th Street North, Swan Lake, MB R0G 2S0
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                LOTTERY MANAGED BY PERFORMANCE PROMOTIONS - 306.782.6541
LORNE MEMORIAL HEALTH FOUNDATION . LOTTO 2011                                                                 INC
                                                                                                                                                           PROCEEDS TOWARDS THE

                                                                                                                                                Lorne Wellness Centre


   only 3500
tickets availab
                le               ONE GRAND PRIZE DRAW winners choice of 5 Grand Prize Packages
               $100 A TICKET                                  OPTION #1                                                                          OPTION #2



                      EARLY
                   BIRD DRAWS

                                          h
                           500.0 Cash Eac
                                                                                     One - Elmers Grain Gart
                       $        0                                                   850 bu AND Three Westeel
                                                                                   Hopper Bins (5904 Bushels),
                                                                                   Three 21’ Comte Cones (809         Material for a 1472 square ft Cottage with free

                             Cash Each
                                                                                  Bushels) with setup and delivery   delivery within 60 miles of Swan Lake AND One
                      $ ,000    .00                                                within 60 Miles of Swan Lake
                       1                                                                                              2011 Sea Doo 150 Speedster with Tower and
                                                                                                                               Bimini top, stereo and a trailer




                                                                                                                                               OPTION #4
                                                              OPTION #3
                       FINAL DRAW
                                                                                                                                       One 2011 Ford Fiesta SE 4 Door AND
                                                                                                                                   One 2011 Ford Escape XLT AWD 3.0L V6 AND
                                                                                                                                     One 2011 Ford F-150 Super Crew XLT 4X4
                                                                          One 2011 Kingsport 26ft Travel
                                                                          Trailer (265BHS) fully equipped
                                                                         including large slideout room and
                                                                fiberglass exterior AND Two 2011 Sea-Doo GTS 4                                   OPTION #5

                                                                                                                      100,000.00 CAS
 TO ORDER TICKETS                                               Stroke 3 Seat PWC’s & a 2 Place PWC Trailer AND

 CALL TOLL FREE
                                                              One 2011 Polaris Ranger RZR 800 EPS LE including
                                                                                                                     $
                                                                                                                                                                                                           H
                                                              a Pure Polaris winch AND One 2011 Harley Davidson




1.855.327.0161
                                                                 FLSTC - Black (Heritage Classic) AND One 2011
                                                               Harley Davidson XL883N - Black Demin (883 Iron)




 OR MAIL ORDERS TO:
 LORNE MEMORIAL HEALTH FOUNDATION INC. LOTTO 2011
 P BOX 130, SWAN LAKE, MB R0G 2S0
  .O.                                                                                                                        www.lmhflotto.com
                                                                                                                                                                      PILOT MOUND
                                                                                                                                  Metcalfe’s
                                                                                                                                                                              P.O. Box 70
                                                                                                                                                                                     Treherne, Manitoba
                                                                                                                                                                                               R0G 2V0
                                                                                                                                  GARAGE LTD.                                Telephone: 1-204-723-2175
                                                                                                                                                                                     Fax: 1-204-723-2497
                                                                                                                                  Manitoba’s Oldest Ford Dealership            Toll Free: 1-800-355-1655
                                                                                                                                                                        Website: www.metcalfesgarage.ca




Lottery License # MGCC 5154RF                       Prizes may not be exactly as shown.

				
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