Person in charge of Ticket:
Name & Address
(Please Print Clearly)

NAME: _________________________________________________________________

ADDRESS: ______________________________________________________________

________________________________________________________________________

CITY: ______________________________________________ STATE: ______________

ZIP CODE: ___________________________ PHONE: ____________________________

Additional Names

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

If available, choice of ticket # _______________________________________________

MAKE A $100.00 CHECK PAYABLE TO:

CAYUGA FIRE DEPARTMENT
MAIL TO: WIN-A-TON
C.F.D.
P.O. BOX 148
CAYUGA, NY 13034