Print and fill out this application & mail
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Name:__________________________________________
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___ Grand Prize Tickets
@ $100 each: $_____
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Address:_________________ Phone:_______________
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___ 'Increase Your Odds'
Tickets @ $20 each: $_____
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City:____________________ State:__ Zip:________
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email:___________________ Fax:_________________
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TOTAL $_____
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Method of payment:  Cash Check Money Order
Visa Discover MasterCard American Express
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Orders will be
acknowledged via
first class mail |
Card#:_____________________ 3 digit Security Code__ __ __
Exp.Date:____/____/____
Your Signature:___________________________________
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| Need not be present to win. Prize winners shall be responsible
for all applicable license fees, delivery charges, local, state, and federal taxes.
Prizes are subject to federal income tax witholding of 25% of value. Must be 18 years of age and licensed driver.
Void where prohibited by law. Winner responsible for delivery expense of vehicle from
Effingham location. Oders will be acknowledged via first class mail. |