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_______________ q 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.