Secure Order Form

Mail To: N.H.S. 40 E.Main Street #364-I Newark, DE-19711
Fax:302-369-8284

Please select the number of tickets you wish to purchase. (Tickets are $100.00 each) Please send me 3 raffle tickets and get 3 free Please send me 1 raffle ticket     Your raffle tickets will be filled out and sent to you. Please supply the following information: Full Name   (required) Address   (required) City   (required) State Zip    (both required) Phone #   (required) Email:   (required)   Choice of prize? (select one)     $50,000.00 Cash     Porsche Carrera     Porsche Cayman-S     Porsche Cayenne    Mercedes Benz    BMW-M3       Corvette       Range Rover   Where did you see our ad? (select one)     Magazine     Postcard     Online If Magazine, which one?   Your payment information: Select one:     Visa     MC     Amex     Discover     Sending Check Account Number   (required for credit cards) Exp. Date (MM/YY)  (required for credit cards) Comments: