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Win4Kids Raffle
Win4Kids Raffle Form
Donation
Payment for Win4Kids Raffle
Please enter information on this form to make payment for
Win4Kids Raffle
.
The amount you need to pay is
$0.00
.
Who Told Your About The Raffle?
Referral First Name
Referral Last Name
Your Information
Your First Name
*
Your Last Name
*
Address
*
Address2
City
*
Province
*
--Select--
ONTARIO
Postal Code
*
Phone
*
Email
*
Individual Tickets: $75
--Select--
1
2
3
4
Five Pack: $300
--Select--
1
2
3
4
Total Amount
$
Payment method
Paypal
Credit Card Number
*
Expiration Date
*
01
02
03
04
05
06
07
08
09
10
11
12
/
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Card (CVV) Code
*
Card Type
*
Visa
MasterCard
Discover
American Express
Card Holder Name
*
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