Secure Order Form

Secure Order Form
(Secure Server Provided by our ISP - HIWAY Technology)
Personal Information

Last Name Given Name

Apt# Street

City Province

Postal Code

Daytime Phone (Area Code) Number

Subscription Plans

Select your six (6) winning numbers
on each game board to the right
and select the Checkbox for the period of time
and the number of games you want to play

No. of
GAMES 26 DRAWS

C$29 C$58

C$58 C$116

C$87 C$174

C$116 C$232

C$145 C$290

C$174 C$348

Or Select Quick Pick.

Select 6 numbers from 1 to 49
GAME 1

- - - - -

GAME 2

- - - - -

GAME 3

- - - - -

GAME 4

- - - - -

GAME 5
- - - - -

GAME 6

- - - - -

TOTAL AMOUNT PAYABLE: C$

Online Payment Information

Credit Card

Expires (mo/yr) /

Card Number

Name on Card

Before You Submit Your Order...
Please make sure that all the information you have provided us is accurate, as we cannot guarantee processing of your order without the correct payment information.
If you would prefer to fax your order, click here.

Contact: [email protected]

Last Name		Given Name
Apt#		Street
City		Province
Postal Code
Daytime Phone	(Area Code)	Number