Wayne Derrick Fundraising Drawing Registration

Today's Date:*

Name:*

Email:* (This is the primary way we communicate with members)

Phone:

Address:*

City:* State:*    Zip: *

Number of tickets:

PLEASE READ BEFORE CLICKING SUBMIT: This form will be sent directly to us and You will be sent to the payment page upon submitting this form. Please check your form of payment below.

Form Of Payment:
Online by Debit or Credit Card through Paypal
Mail check to TTFHA, Inc c/o Wayne Reed (Treasurer) | P O Box 776 | Silverton, TX 79257


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