To order tickets, please complete this form, print  or fax and mail.

If you wish to place a phone order for tickets call (519) 662-2623

Name |__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__|

Address |__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__||__|

City|__||__||__||__||__||__||__||__||__||__||__||__||__| Prov   ONTARIO  (Due to rules & regulations of the lottery license orders from
                                                                                                                                                             outside of Ontario will not be accepted)

Postal Code |__||__||__|   |__||__||__|

Telephone |__||__||__|-||__||__||__|-|__||__||__||__|

Number of Tickets |__| x $5.00 = |______|

Number of Tickets |__| sets of 5 x $20.00 = |______|

|_| CHEQUE

|_| INTERNATIONAL MONEY ORDER

|_| VISA

|_| MASTERCARD

Credit Card Number |__|__|__|__|  |__|__|__|__|  |__|__|__|__|  |__|__|__|__|        |_||_| MM      |_||_| YY

Signature ________________________________

Make cheques payable to:  Optimist Club of New Hamburg

Mail us at:

Optimist Club of New Hamburg
170 Arnold St
New Hamburg, Ontario
N3A 1R5  
email inquiries: mvmiller@sympatico.ca

Telephone:  519-662-2623

For Faxing  in orders (519) 662-2547