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Online Internet Lottery Ticket Purchase

Please complete the form provided below.

REGISTER HERE

Mr. Ms. Mrs. Miss Dr.
Required only if Last Name below is to be filled.

Last Name
Group Name

First Name

Address: STREET

CITY

PROVINCE

POSTAL CODE

Contact Phone No.

Mode of response
LOTTO XPRESS INC. will communicate the necessary information to you based on the mode indicated below.

Select one only

FAX		Enter the number here
E-MAIL		Enter your e-mail address here:
POST		We will post it to the address indicated above.

Please PRINT this page before you click on the 'Submit' button. This is for your records.