Leaves of Class Entry Form

Over $12,700 in gifts.

Your $20 donation means 12 chances to win extraordinary prizes! Your
presence is not required at monthly drawings.

A limited number of chances will be sold. The drawing will begin on 31 January 2009 and continue through 31 December 2009.

* First Name:

   Middle Initial:

* Last Name:

* Billing Address:

* City:

* State:

* Zip/Postal Code:

   Email Address:

*Home Phone Number:

Work/Cell Phone:

Ticket Order Quantity   Price Total

Number of Tickets x $20 = $

       Grand Total: $

* Method of Payment:

* Credit Card Number:

* Expiration Date:

Gift envelopes available by calling 570-941-7816

I would like to receive email notification about future Library events.

* Fields marked with a red asterisk are required fields.