Motorcycle/RZR Raffle Tickets
Amount
$1000 for 75 Tickets
$500 for 35 Tickets
$100 for 6 Tickets
$20 for 1 Ticket
Type of Donation
One Time Donation
Recurring Donation
Frequency
Monthly
Contact Information
First Name
Last Name
Company Name
Address
Address 2
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Help Us Cover Costs
Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.
Yes! I want $0.00 to go to Boys & Girls Club of Farmington and I will donate $0.00.
No. I will donate $0.00 and Boys & Girls Club of Farmington will cover the processing costs.
Credit Card Information
Card Holder Name
Visa
MasterCard
Discover
Card Account Number
Expiration Date
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
24
25
26
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28
29
30
31
32
33
34
Security Code
Billing Address
Same As Above
Address
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
Email
Your entry is not a valid email address!
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Boys & Girls Club of Farmington 1925 Positive Way Farmington NM 87401 505-327-6396 www.bgcfarmington.org
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