Draw Down Raffle Ticket Order Form
Name___________________________________________________________________
Address_________________________________________________________________
Cell Phone__________________________ Email:________________________________
Indicate Number/Type of Ticket Below
_____ Draw Down Ticket (s) @$50 each
_____ Draw Down Ticket(s) w/ *Insurance @ $75 each
(*If ticket is one of the first 50 drawn, it will be returned to Draw Down barrel for a second chance)
( ) Cash
( ) Check payable to Georgia Healthy Family Alliance
( ) Credit Card ___________________________________ Billing Zip___________
Expiration __________________ V-CODE ______________________________
Please check all that apply (even if you plan to attend)
_____If my name is one of the last 4 names remaining and the other 3 remaining names agree, I wish to split the $10,000 four ways winning $2,500.
_____If my name is one of the last 3 names remaining and the other 2 remaining names agree, I wish to split the $10,000 three ways winning $3,333.33.
_____If my name is one of the last 2 names remaining and the other remaining name agrees, I wish to split the $10,000 two ways winning $5,000.
I do not wish to split at any level.
_____If I win I would like to donate $_____ to the Georgia Healthy Family Alliance
Georgia Healthy Family Alliance ~ Georgia Raffle License No. 2015033
3760 LaVista Road, Suite 100 Tucker, GA 30084-5641
404.321.7445 Phone / 800.392.3841 Toll Free/ 404.321.7450 Fax
Email: ksinkule@gafp.org