Winnipeg Free Press (Newspaper) - August 1, 2013, Winnipeg, Manitoba
C M Y K PAGE A15
winnipegfreepress. com XYFOLIOXY WINNIPEG FREE PRESS, THURSDAY, AUGUST 1, 2013 A 15
PURCHASER INFORMATION .. Mr. .. Mrs. .. Ms. .. Miss .. Dr.
* First Name ________________________ * Last Name _______________________________________
* Address ____________________________________________________________________________
* City/ Town ________________________ * Province _____________ * Postal Code _______________
Phone: Home ( )_____________ Work ( ) ______________ Cell ( )_______________
Email _______________________________________________________________________________
METHOD OF PAYMENT
.. Money Order .. Cheque Payable to St- Boniface Hospital Foundation . Please, no post- dated cheques.
.. ..
Card#
Expiry: /
Signature ___________________________________________________________________________
Fax your ticket order form to fax to 204- 231- 0041
or mail to St- Boniface Hospital Foundation PO BOX 73 RPO Norwood Grove, Winnipeg MB R2H 9Z9
TICKET ORDER FORM
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Single Ticket ______ @ $ 10 each = $ __________
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