Raffle Ticket Sales (Internal)

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Please complete the form below for every raffle ticket sale. Most fields are required.

Note:This form requires JavaScript to be enabled, so that it can correctly process your information. Because this is a secure site, some browsers may prevent JavaScript from working. Please disable any blocking that may be in effect on this page.

Ticket Information

Number of Raffle Tickets: (each ticket is $100)

Personal Information

First Name:
Middle Initial:
Last Name:
Phone Number:
Personal eMail Address:

Additional Questions

Salesperson Name:
Donor to attend drawing on November 9, 2015:

Billing Information

Address 1:
Address 2 (optional):
Address 3 (optional):
ZIP Code:
City:
State:

Payment Information

Payment Type:

Credit Card
Check

Name on Credit Card:
Credit Card Number: (digits only)
CV2:
Expiration Date:
Bank Routing Number: (digits only)
Account Number: (digits only)
Check Number: (digits only)
Check Type: Company
Personal
Account Type: Savings Account
Checking Account


THIS IS A 256-BIT SECURE TRANSACTION

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