Complete and mail this form to:

Neuromuscular Disease Foundation

269 S. Beverly Dr #1206

Beverly Hills, CA 90212

Or fax it to:

310-276-2108

Number of Tickets:

x $100 per ticket = Total Amount:

q Check enclosed – payable to Neuromuscular Disease Foundation

Or, please charge my (check one):

q VISA

q MasterCard

q American Express

q Discover

Card Number:

Security Code:

Expiration Date:

(last three numbers on signature line on back of credit card, or four digits on the front of American Express, above the account number)

Signature:

Email Address:

Please print legibly so we may process your order without delay:

Name On Credit Card:

Phone:

Billing Address:

City:

State:

Zip:

Name To Appear On Ticket:

Phone:

Mailing Address For Ticket:

City:

State:

Zip:

Email:

How did you hear about the raffle?

Did a friend refer you? If so, give their full name and city to enter them into the "Refer-A-Friend" drawing:

(One name only)

Name:

City, State:

2010 Merc edes Benz Drawing

You may also order by phone, providing the

above information, by calling toll free:

310-276-2980

All entries received OR POSTMARKED before the drawing deadline(s) will be entered into the associated drawing and all subsequent drawings whether or not your ticket stub has been mailed to you. Your numbered ticket receipt(s) will be mailed to you after your check or credit card is processed. Although it may take four weeks before you receive your receipt(s), the raffle ticket(s) with matching numbers will be placed in the official drum for the drawings. ALL SALES ARE FINAL. NO REFUNDS.. Must be 18 years or older to enter. Void where prohibited. Raffle subject to rules and regulations available at www.ndf-hibm.org.