Please Print

Name: __________________________________

Address: ________________________________

State: ___________________________________

Zip: __________

Phone: __________________________________

Email ___________________________________

Signature: ________________________________


Please fill in the above form and print it out and mail it with the money too

Battered Mothers Resource Fund/ Raffle
P.O. Box 7166
Columbia Missouri,65202
ATTN: RAFFLE

Thank you and good luck