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 rule & regulations of the lottery licence 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