NORTHMONT ELEMENTARY PTA SUPPORTS

2010 La Mesa Chamber-DCH Honda CR-V Drive Away

ENTER BY PHONE You may order by phone, providing the same information as requested on this form by calling 619-867-6562 OR

ENTER BY MAIL OR FAX Complete & return this form to: La Mesa Chamber CR-V Drive Away

8080 La Mesa Blvd. #212 La Mesa, CA 91942 Or fax to: 619-465-1693

Please print legibly so we may process your order without delay

Number of Tickets:____ x $25 per ticket = Total Amount: $_______ Multi-Ticket Discount - 5 for $100 Number of multi-ticket packs _____ x $100 = $________ Check enclosed, payable to: La Mesa Chamber CRV Drive Away Cash OR CREDIT CARD VISA MasterCard Discover American Express Card Number:_______________________________ Expiration Date:_______ Security Code*:______ * Last three numbers on signature line on back of credit card, or four digits on the front of American Express, above the account number.

Signature:______________________ Name On Credit Card:____________________ Billing Address:__________________________________ City:___________________ State:____ Zip:________ Phone (include area code): _______________Email Address:____________________ Name (only 1) To Appear On Ticket:_______________________________________________ Mailing Address For Ticket:________________________________________________ City:_____________________ State:_____________ Zip:________________ Phone (include area code): _______________Email Address:______________________ How did you hear about the raffle?__________________________________________ I was referred by the following friend (full name) Northmont Elementary PTA Friend’s City, State La Mesa, CA

All entries received before the drawing deadline(s) will be entered into the associated drawing and all subsequent drawings whether or

not your ticket stub has been mailed to you. Your numbered ticket receipt(s) will be mailed to you after your check or credit card is

processed. Although it may take four weeks before you receive your receipt(s), the raffle ticket(s) with matching numbers will be placed

in the official drum for the drawings. ALL SALES ARE FINAL. NO REFUNDS. Only 4,000 tickets will be sold. Must be 18 years or older

to enter. Void where prohibited. Raffle subject to rules and regulations. © La Mesa Chamber of Commerce. All rights reserved.

Referring Friend must also be a ticket holder to be in the refer-a-friend drawing.