Cash Bonanza Lottery Order Form

Yes, I would like to support the Epilepsy Centre by purchasing tickets in the Cash Bonanza Lottery.

Option 1

I would like to purchase ............ tickets @ $30.00 each $................

Please find enclosed my cheque/money order or

Debit $................... from my

Bankcard

Visa

AMEX

Mastercard

Diners

Card No................/................/................/................

Name on card..........................................................

Expiry Date................/................

Signature.................................................................

Please note: The Epilepsy Centre is unable to accept credit card payments by email.

Option 2

Please invoice me for _______ tickets @ $30.00 each $________

Ticket Buyer Details
Title Dr/ Mr / Mrs / Ms

First Name................................................................

Surname...................................................................

Organisation..............................................................

Address....................................................................

Suburb............................................. State................

Postcode..................................................................

Phone (daytime)........................................................

Fax..........................................................................

Email.......................................................................

Please mail: Epilepsy Centre, P O Box 12, Woodville SA 5011
Or
Fax (08) 8445 6387