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Heart&Stroke Lottery Ticket Order Form
ONLY 240,000 TICKETS AVAILABLE. VALID FOR Winter 2009-2010 only.

Please fill in the form on screen, click on "Print Form", sign and Mail/Fax.

Purchaser Information
Fields marked with * must be filled in.
Salutation: Mr. Mrs. Ms. Miss Mr. & Mrs.
* First Name
* Last Name
* Address
* City
* Province * Postal Code
* Home Tel No   
Bus. Tel No.    ext:
Age 18-34 35-49 50-64 65+
Email Address

Please send to the above address:

ticket(s) at $100 each for a total of $
3-pack(s) at $250 each for a total of $
All 3 tickets must contain the same information  
I'm enclosing a charitable donation of $
Tax receipts can only be issued for donations.  
  Total: $
This ticket is a gift
Name to appear on ticket
Phone Number

Method of Payment:

Cheque Money Order Visa MasterCard Amex
Make cheque\money order payable to: Heart&Stroke Lottery. No post-dated cheques will be accepted.
Credit Card Number:
 Expiry Date:
/
Cardholder's Name
 Cardholder's Telephone
ext.
Cardholder's Signature
By entering this lottery: I acknowledge I have read and understood the rules and regulations of this lottery and confirm I am at least 18 years of age, and have purchased the ticket within the province of Ontario. Please allow a minimum of two weeks for delivery of ticket(s).
We are committed to protecting the privacy of your personal information. We may maintain a record of your interaction for donor-related, promotion and tax receipting purposes, where required. Occasionally, we may contact you with mission-related communications. If you wish no further contact or have any questions or concerns regarding the privacy of your personal information, please contact the Chief Privacy officer, at your provincial Heart and Stroke Foundation office at 1-888-HSF-INFO (473-4636). The Heart&Stroke Lottery does not share lists with other organizations. Lottery License #2073

THANK YOU FOR YOUR SUPPORT Mail to: Heart&Stroke Lottery
PO Box 42007 STN BRM B
Toronto, ON, M7Y 7J7		 Fax to: Heart&Stroke Lottery
416-650-7851
1-888-551-5542
NEW! The ONLY Charity Lottery offering a TOP PRIZE of $1.5 Million CASH!
CALL 416 661-1511 or 1-888 551-1111