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First Name*
Last Name*
State*
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Mobile*
Email*
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Your lucky numbers will be emailed to you. Winners may be notified by email.
Year of Birth*
By law you must be over 18 years of age to enter the raffle draw
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Number of Tickets
Optional Extra Donation
Donations are tax deductible your receipt will be emailed
Name on Card*
Card Type*
Card Number*
Expiry Month*
Expiry Year*
CVV*

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