Back to Contents

To Use This Form
1. Complete your name, address, and phone number.
2. Choose a Discount Package, if applicable.
3. Use chart on opposite page to make your prize selections.
4. Complete the method of payment.
5. Enter ticket totals.
6. Add up your total.
7. Place your order.

Ordered By
*required

*Name:

Address:

City: State: Zip:

*Phone:

*Email:

With which NCSY region are you affiliated?
New York   Southern   New England   Central East   West Coast   Upstate

How did you hear about the website?
Yated
Hamodia
Jewish Press   		 Lifestyle
Image
Blue Light   		 Onlysimchas
JM in the AM   
Mail		 Poster
Book
Other (please specify):


Discount Packages
Check applicable amount

$125 buys coupons worth $160
$225 buys coupons worth $336
$360 buys coupons worth $550
$500 buys coupons worth $880
$750 buys coupons worth $1350
$1000 buys coupons worth $2200 or a ticket in every box!


Payment Method

Visa
MasterCard
American Express

Card No.:

Expiration Date:


Prize Selection
Make selections by typing the amount of
tickets you want in the appropriate box
  $75    $25    $10
1A 1D 1F
2A 2D 2F
3A 3D 3F
4A 4D 4F
      5D 5F
$50 6D 6F
1B 7D 7F
2B 8D 8F
3B 9D 9F
4B 10D 10F
5B 11D 11F
6B 12D 12F
7B       13F
8B $18 14F
      1E 15F
  $36 2E 16F
1C 3E 17F
2C 4E 18F
3C 5E 19F
4C 6E 20F
5C 7E 21F
6C 8E 22F
7C 9E 23F
8C 10E 24F
9C 11E 25F
10C 12E      
11C 13E      
      14E      
      15E      
      16E      
      17E      
       18E      
      19E      
      20E      

Ticket Totals
Enter your totals from the left chart

$75 tickets = $
$50 tickets = $
$36 tickets = $
$25 tickets = $
$18 tickets = $
$10 tickets = $

Total face value of tickets ordered:



Amount Due
Discount Package: $
(or face value if discount package not applicable)

Additional amount over Discount Package: $

Grand Prize: tickets = $
Not included in package: 1 chance for $75, 3 for $150
Only 750 chances will be sold

Split the Pot: tickets = $
Not included in package: $10 a chance, 3 for $25, 5 for $36

Jackpot Raffle: tickets = $
Not included in package: $10 a chance, 3 for $25

Total Due: $