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<strong>                         Third Prize <strong>$1000 <strong>~~ Fourth Prize $360</strong></strong></strong></span><span style="color: rgb(0, 255, 0);"></span><strong>                    <span style="color: rgb(255, 0, 0);"></span></strong></p>
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<span style="font-size: 20px;">RAFFLE <strong>                      </strong><span style="color: rgb(255, 0, 0);">ENDS</span> THIS WEDNESDAY <span style="color: rgb(255, 0, 0);">21 JULY</span> AT MIDNIGHT EST</span></p>
<hr>
<p class="SCHP_Headline"><em>First Name*:</em>                    <input tabindex="1" required="true" name="First Name" type="text">  </p>
<p class="SCHP_Headline"><em>Last Name*:</em>                    <input tabindex="1" required="true" name="Last Name" type="text">  </p>
<p class="SCHP_Headline"><em>Email address*:               <input tabindex="1" required="true" name="Email" type="text"></em>   <br>
<br>
<em>Confirm Email Address*: </em> <input tabindex="1" required="true" name="Email Confirm" type="text">  </p>
<p class="SCHP_Headline">
<em>Phone Number*:              <input tabindex="1" required="true" name="Phone Number" type="text">  </em></p>
<p class="SCHP_Headline"> </p>
<p class="SCHP_Headline">
<span style="font-family: Verdana; color: #800000">Number of tickets*:</span></p>
<p class="SCHP_Headline"><span style="font-family: Verdana; color: #333399">
<script type="text/javascript">
function update(str1) { 
 document.getElementById('textbox').value = str1;
}
</script><select onchange="update(this[selectedIndex].value)" style="width: 238px; font-weight: 700" name="Number of Tickets">
<option value="1 Ticket - £25">1 Ticket - £25</option>
<option value="2 Tickets - £50">2 Tickets - £50</option>
<option value="3 Tickets - £75">3 Tickets - £75</option>
<option value="4 Tickets - £100">4 Tickets - £100</option>
<option value="5 Tickets - £125 + 1 Bonus Prize Entry">5 Tickets - £125 + 1 Bonus Prize Entry</option>
<option value="6 Tickets - £150 + 1 Bonus Prize Entry">6 Tickets - £150 + 1 Bonus Prize Entry</option>
<option value="7 Tickets - £175 + 1 Bonus Prize Entry">7 Tickets - £175 + 1 Bonus Prize Entry</option>
<option value="8 Tickets - £200 + 1 Bonus Prize Entry">8 Tickets - £200 + 1 Bonus Prize Entry</option>
<option value="9 Tickets - £225 + 1 Bonus Prize Entry">9 Tickets - £225 + 1 Bonus Prize Entry</option>
<option value="10 Tickets - £250 + 2 Bonus Prize Entries">10 Tickets - £250 + 2 Bonus Prize Entries</option>
<option value="20 Tickets - £500 + 4 Bonus Prize Entries">20 Tickets - £500 + 4 Bonus Prize Entries</option>
<option value="30 Tickets - £750 + 6 Bonus Prize Entries">30 Tickets - £750 + 6 Bonus Prize Entries</option>
<option value="40 Tickets - £1000 + 8 Bonus Prize Entries">40 Tickets - £1000 + 8 Bonus Prize Entries</option>
</select></span>  </p>
<p class="SCHP_Headline"><strong>We can accept Visa and Mastercard credit cards and debit cards (not AMEX)</strong> </p>
<p class="SCHP_Headline">Card Type*:        <select tabindex="1" name="Visa">
<option value="Visa" selected>Visa</option>
<option value="Mastercard">Mastercard</option>
</select></p>
<p class="SCHP_Headline">Name on card*:  <em><em>                          <input tabindex="1" required="true" name="Name on Card" type="text"></em>       </em></p>
<p class="SCHP_Headline">Billing Address*: <em><em>                                <input tabindex="1" required="true" name="Billing Address" type="text"></em> </em></p>
<p class="SCHP_Headline">City*:                <em><em>                                 <input tabindex="1" required="true" name="City" type="text"></em>                     </em></p>
<p class="SCHP_Headline">County/State:    <em><em>                               <input tabindex="1" required="false" name="State" type="text"></em> </em></p>
<p class="SCHP_Headline">Postcode*:        <em><em>                                 <input tabindex="1" required="true" name="Postcode" type="text"></em>              </em></p>
<p class="SCHP_Headline">Country<em>*:          </em><em>                      <input tabindex="1" required="true" name="Country" type="text"></em> </p>
<p class="SCHP_Headline">Card Number*:  <input tabindex="1" required="true" name="Card Number" type="text">       </p>
<p class="SCHP_Headline">Security Code*: <em><em>                          <input tabindex="1" required="true" name="Sec Code" type="text"></em> </em></p>
<p class="SCHP_Headline">Expiration Date*: <span style="font-size: 10pt"><select tabindex="1" name="Exp Month">
<option value="Jan" selected>Jan</option>
<option value="Feb">Feb</option>
<option value="Mar">Mar</option>
<option value="Apr">Apr</option>
<option value="May">May</option>
<option value="Jun">Jun</option>
<option value="July">July</option>
<option value="Aug">Aug</option>
<option value="Sept">Sept</option>
<option value="Oct">Oct</option>
<option value="Nov">Nov</option>
<option value="Dec">Dec</option>
</select> <select tabindex="1" name="Exp Year">
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024" selected>2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
</select>                  </span></p>
<p class="SCHP_Headline"> </p>
<p class="SCHP_Headline">
<em>
<span style="white-space: normal; word-spacing: 0px; text-transform: none; float: none; color: rgb(0,0,0); font: 18px/21px Georgia; display: inline !important; letter-spacing: normal; background-color: rgb(255,255,255); text-indent: 0px; -webkit-text-stroke-width: 0px">Please note: Your ticket/s will be issued once we receive confirmation of a successful payment. <strong>This is not immediate in our system</strong>. You will receive confirmation of a successful purchase once your card has been processed. <br>
<br>
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