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The Coutts Memorial Museum of Art
110 N. Main, El Dorado, KS 67042
(316) 321-1212

RAFFLE TICKET ORDER FORM

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___________

Name:_________________________________________Telephone:______________________
Address:_______________________________________________________________________
City:___________________________________________State:_____Zip:__________________
E-mail:________________________________________________________________________

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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