2010 Corvette Raffle

Easy Order Form

Please fill out the following information. After you click 'Submit' you will be taken to a page with a printable version of your information. Please print that page and mail it to:

Defance Rotary Foundation
P. O. Box 7177, Defiance, Ohio 43512

First Name:

Last Name:

Address:

City/State:

Zip:

Daytime Phone Number:

How many tickets do you want to purchase?

How much money are you including with your order form? (number of tickets x $100)
$