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Order must be received by Monday, June 17, 2019

__________ Number of ticket books requested, at $15 each (6 tickets per book)

__________ Total payment

Paid by check ____ credit card ____ (please complete CC information below)

Name _______________________________________________________________

Address ___________________________________________________________________

City ___________________________ State __________ Zip ________

Phone# (____) ___________________

E-mail address _________________________________________

MC/Visa: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __   Exp: mo___ /yr___

Signature: ________________________________________

Print, complete and mail this page to:
The Helpers Fund
6318 B Main Street
PO Box 691
Chestertown, NY 12817

Thank you for your support!

The Helpers Fund is a 501(c)3 charity certified by the Internal Revenue Service and governed by the IRS Regulations governing charities. The Fund is incorporated under the laws of New York State's Department of State, and is registered with the New York State Bureau of Charities.

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