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Please
print this page, complete the form, and mail the form along
with your check to:
_____ I would like to take part in the benefit by pruchasing raffle tickets at $5 each or 6 tickets for $25 at the Coutts Membership Reception on February 17, 2011..
Number of tickets__________
Total $ enclosed___________
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Name:_________________________________________Telephone:______________________
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Address:_______________________________________________________________________
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| City:___________________________________________State:_____Zip:__________________ |
E-mail:________________________________________________________________________
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Payment Options:
______Check (payable to Coutts Museum) _____Credit Card
Name on Card____________________________________ MasterCard, Visa, Discover (Circle one)
Card #__________________________________________ Expiration Date___________________
Cardholder Signature_______________________________________________________________
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