To request a ticket, fill in the necessary information below, print this page, and mail it, along with payment to: LISTOWEL KINSMEN CLUB, C/O LOTTERY DRAW Box 122, Listowel, Ontario N4W 3H2 The Chairman, Kinsmen, K-40 and Kinettes, wish to offer you our most sincere thanks for supporting The Listowel Kinsmen Club and our community, in the past, by supporting our annual lottery. Last Name : First Name: Address:   Suite / Appt : City / Town:    Province: AB BC MB NB NL NT NS ON PE QC ST YT  Postal Code:   Phone (Day): ( ) - Ext Phone (Evening): ( ) - Email: Send me future information by email: Yes No        Send me future information by mail: Yes No Please send me at $100.00 each. . . . . . . . .Total: (Note: If you wish to have a different name put on the ticket(s) include a seperate sheet with names for each ticket) Select Payment type: Money Order Cheque Visa MasterCard Make cheques payable to: LISTOWEL KINSMEN CLUB Card Number: Expiry Month: 01 02 03 04 05 06 07 08 09 10 11 12 Expiry Year: 11 12 13 14 15 16 17 18 19 Signature: Ontario Lottery Licence Number M-515707                                                                 Official ticket will follow.