LEAVES OF CLASS

You may pay by credit card or electronic check.
Please complete this form to process your payment.

Your $20 donation means 12 chances to win extraordinary prizes!
Your presence is not required at monthly drawings.
A limited number of chances will be sold.
The drawing will begin on
31 January 2012 and continue through 31 December 2012.

Personal Information: (* Required Field)
*First Name:
Middle Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Area Code / *Home Phone #:
*Area Code / *Cell/Work Phone #:
*Email:
Ticket Order Quantity Price Total
Number of Tickets x $20 = $
Grand Total: $
* Method of Payment:
Gift envelopes available by calling 570-941-7816
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