Purchase Tickets - Royal Life Saving WA

REFERENCE NUMBER

6-digit Reference Number

There is no active raffle to purchase tickets for at this time.

Suggested amount: ${{suggestedAmount}}

BILLING DETAILS

Call Centre Integration

Coupon ID

First Name

Last Name

Email Address Invalid email address format Allow purchase without customer email address (send to {{adminMailboxForPurchasesWithoutEmail}})

10-digit Phone Number (include area code for land line)

Date of Birth - Day

Date of Birth - Month

Date of Birth - Year

Gender

CASH PAYMENT DETAILS

{{Data.CustomPurchaseSettings.CashPaymentAgentUsernamePlaceholderText}}

Amount Collected

PAYMENT DETAILS

Cardholder Name

Expiry Month

Expiry Year

AUTHORISATION

I understand that this is not a one-off ticket purchase.

Please confirm you understand and agree to the monthly commitment

I understand that this is an ongoing monthly financial commitment.

Please confirm you understand and agree to the monthly commitment

Please confirm you understand and agree to the direct debit service agreement terms and conditions

Preferred Withdrawal Date

Enter any comments you would like to make here (optional)

Signature Pad

Clear signature

(Sign with mouse on desktop, or finger on mobile device)

Please fill out all the required fields correctly.

QUANTITY: {{selectedNumTickets | number}} TOTAL: {{selectedNumTickets * Data.RaffleStoreItem.Price | currency}}

DISCOUNT: {{discountAmount | currency}} TOTAL: {{cartPrice | currency}}

TOTAL MONTHLY AMOUNT: {{calculateTotal() | currency}} PAY NOW

CHECKOUT