Name:  ____________________________________________________

Mailing Address:  ____________________________________________

Postal Code:  _____________________  Phone:  __________________

Visa #:  __________________________________ Expiry ____________

Mastercard #:  _____________________________ Expiry ___________

American Express #: ________________________ Expiry ___________

Permission Signature for Credit Card:  ___________________________

Cheque ____  Money Order ____ Payable to Brookfield Lotta Truck

I wish to purchase ____ tickets @ $100.00 each

Mail to:    Brookfield Lotta Truck, 55 Carter Road, Brookfield, NS   B0N 1C0

Fax:        902-673-2775