tickets.nanaimohospice.com
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URL:
https://tickets.nanaimohospice.com/
Submission: On January 01 via automatic, source certstream-suspicious — Scanned from CA
Submission: On January 01 via automatic, source certstream-suspicious — Scanned from CA
Form analysis 1 forms found in the DOM
POST https://tickets.nanaimohospice.com
<form action="https://tickets.nanaimohospice.com" method="POST" id="checkoutForm" novalidate="novalidate">
<input type="hidden" name="_token" value="AbbOwXvAuVhajLigIyQoaulZ1dVv9hgbqxRf4y2Z">
<input type="hidden" name="checkout_opened_at" value="2022-01-01 00:35:43">
<div class="bg-info well well-lg ">Tickets may be sold and purchased in British Columbia only. Orders will not be accepted via the Internet from anyone outside of British Columbia or any non-residents of British Columbia.</div>
<div class="hpanel hblue form-horizontal" id="field_group_eligibility">
<div class="panel-heading"> Eligibility Confirmation </div>
<div class="panel-body">
<div class="form-group
age-over-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right">
</label>
<div class="col-sm-9">
<div class="checkbox">
<label>
<input class=" " type="checkbox" required="required" id="age_over" name="age_over" value="Y" aria-required="true">
<b>I am 19 years of age or older.</b>
</label>
</div>
</div>
</div>
<div class="form-group
in-province-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right">
</label>
<div class="col-sm-9">
<div class="checkbox">
<label>
<input class=" " type="checkbox" required="required" id="in_province" name="in_province" value="Y" aria-required="true">
<b>I am in the Province of British Columbia when placing this order.</b>
</label>
</div>
</div>
</div>
<div class="form-group
terms-of-use-acceptance-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right">
</label>
<div class="col-sm-9">
<div class="checkbox">
<label>
<input class=" " type="checkbox" required="required" id="terms_of_use_acceptance" name="terms_of_use_acceptance" value="Y" aria-required="true">
<b>I have read and agree to the <a href="https://rafflenexus.com/terms-of-use" target="_blank">Terms of Use</a> and <a href="rules-of-play" target="_blank">Rules of Play</a>.</b>
</label>
</div>
</div>
</div>
</div>
</div>
<div class="row" id="ticket-packs">
<div class="col-md-6">
<div class="hpanel hblue">
<div class="panel-heading">Home Lottery</div>
<div class="panel-body">
<p><img src="themes/lottery/nchs2021/logo.png" alt="2021 Dream Home Lottery" class="lottery-logo" style="max-height: 125px; margin: 0px auto;"></p>
<div class="form-horizontal">
<div class="row form-group">
<label class="control-label col-sm-4 col-sm-4-ex col-sm-4-ex-half"> Single Ticket </label>
<div class="col-sm-4 col-sm-4-ex col-sm-4-ex-half">
<label class="sr-only" for="qty1">Amount</label>
<div class="input-group">
<div class="input-group-addon input-group-addon-button" data-controls="qtyA1" data-add="-1">−</div>
<input type="text" min="0" max="9" maxlength="1" class="qty form-control input-group-button-input" autocomplete="qty-20220101003543" name="qtyA1" id="qtyA1" data-ticket-type="A" data-price="100.00" data-ticket-qty="1" value="">
<div class="input-group-addon input-group-addon-button" data-controls="qtyA1" data-add="1">+</div>
</div>
</div>
<label class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half control-label">
<div class="text-left">x $100.00 <span id="total_qtyA1"></span></div>
</label>
</div>
<div class="row form-group">
<label class="control-label col-sm-4 col-sm-4-ex col-sm-4-ex-half"> 5-Ticket Pack </label>
<div class="col-sm-4 col-sm-4-ex col-sm-4-ex-half">
<label class="sr-only" for="qty2">Amount</label>
<div class="input-group">
<div class="input-group-addon input-group-addon-button" data-controls="qtyA2" data-add="-1">−</div>
<input type="text" min="0" max="9" maxlength="1" class="qty form-control input-group-button-input" autocomplete="qty-20220101003543" name="qtyA2" id="qtyA2" data-ticket-type="A" data-price="400.00" data-ticket-qty="5" value="">
<div class="input-group-addon input-group-addon-button" data-controls="qtyA2" data-add="1">+</div>
</div>
</div>
<label class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half control-label">
<div class="text-left">x $400.00 <span id="total_qtyA2"></span></div>
</label>
</div>
</div>
<p> Tickets quantity: <span id="total_qty_A">No tickets selected.</span>
</p>
<div class="well bg-info better-option" id="better_option_A" style="display: none;"></div>
<p>BC Gaming Event Licence #128993</p>
<div class="clearfix"></div>
</div>
</div>
</div>
<div class=" col-md-6 ">
<div class="hpanel hblue">
<div class="panel-heading">50/50</div>
<div class="panel-body">
<div class="jackpot-info m-t-md"> Current 50/50 Jackpot </div>
<div class="jackpot-value">$122,400</div>
<div class="jackpot-info m-b-md">Winner takes half</div>
<div class="form-horizontal">
<div class="row form-group">
<label class=" col-sm-4 col-sm-4-ex control-label"> Single Ticket </label>
<div class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half ">
<label class="sr-only" for="qty1">Amount</label>
<div class="input-group">
<div class="input-group-addon input-group-addon-button" data-controls="qtyB1" data-add="-1">−</div>
<input type="text" min="0" max="9" maxlength="1" class="qty form-control input-group-button-input" autocomplete="qty-20220101003543" name="qtyB1" id="qtyB1" data-ticket-type="B" data-price="25.00" data-ticket-qty="1" value="">
<div class="input-group-addon input-group-addon-button" data-controls="qtyB1" data-add="1">+</div>
</div>
</div>
<label class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half control-label">
<div class="text-left">x $25.00 <span id="total_qtyB1"></span></div>
</label>
</div>
<div class="row form-group">
<label class=" col-sm-4 col-sm-4-ex control-label"> 5-Ticket Pack </label>
<div class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half ">
<label class="sr-only" for="qty2">Amount</label>
<div class="input-group">
<div class="input-group-addon input-group-addon-button" data-controls="qtyB2" data-add="-1">−</div>
<input type="text" min="0" max="9" maxlength="1" class="qty form-control input-group-button-input" autocomplete="qty-20220101003543" name="qtyB2" id="qtyB2" data-ticket-type="B" data-price="100.00" data-ticket-qty="5" value="">
<div class="input-group-addon input-group-addon-button" data-controls="qtyB2" data-add="1">+</div>
</div>
</div>
<label class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half control-label">
<div class="text-left">x $100.00 <span id="total_qtyB2"></span></div>
</label>
</div>
</div>
<p> Tickets quantity: <span id="total_qty_B">No tickets selected.</span>
</p>
<div class="well bg-info better-option" id="better_option_B" style="display: none;"></div>
<p>BC Gaming Event Licence #129003</p>
<div class="clearfix"></div>
</div>
</div>
</div>
<div class="col-md-12">
<div class="hpanel hblue">
<div class="panel-heading">WestJet Ticket Raffle</div>
<div class="panel-body">
<div class="form-horizontal">
<div class="row form-group">
<label class=" col-sm-4 col-sm-4-ex control-label"> Single Ticket </label>
<div class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half ">
<label class="sr-only" for="qty1">Amount</label>
<div class="input-group">
<div class="input-group-addon input-group-addon-button" data-controls="qtyC1" data-add="-1">−</div>
<input type="text" min="0" max="9" maxlength="1" class="qty form-control input-group-button-input" autocomplete="qty-20220101003543" name="qtyC1" id="qtyC1" data-ticket-type="C" data-price="25.00" data-ticket-qty="1" value="">
<div class="input-group-addon input-group-addon-button" data-controls="qtyC1" data-add="1">+</div>
</div>
</div>
<label class=" col-sm-4 col-sm-4-ex col-sm-4-ex-half control-label">
<div class="text-left">x $25.00 <span id="total_qtyC1"></span></div>
</label>
</div>
</div>
<p> Tickets quantity: <span id="total_qty_C">No tickets selected.</span>
</p>
<div class="well bg-info better-option" id="better_option_C" style="display: none;"></div>
<p>BC Gaming Event Licence #129603</p>
<div class="clearfix"></div>
</div>
</div>
</div>
</div>
<div class="hpanel hbgblue">
<div class="panel-heading">Grand Total</div>
<div class="panel-body">
<h2 class="text-center grand_total" data-value="0">$0</h2>
</div>
</div>
<div class="bg-info well well-lg ">All fields in 'bold' are required.</div>
<div class="hpanel hblue form-horizontal" id="field_group_personal_data">
<div class="panel-heading"> Contact Information </div>
<div class="panel-body">
<div class="form-group
first-name-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> First Name </label>
<div class="col-sm-9">
<input type="text" class="form-control " maxlength="45" required="required" id="first_name" name="first_name" value="" aria-required="true">
</div>
</div>
<div class="form-group
last-name-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Last Name </label>
<div class="col-sm-9">
<input type="text" class="form-control " maxlength="45" required="required" id="last_name" name="last_name" value="" aria-required="true">
</div>
</div>
<div class="form-group
apartment-number-form-group
">
<label class="col-sm-3 control-label text-right"> Apartment/Unit # </label>
<div class="col-sm-9">
<input type="text" class="form-control " maxlength="20" id="apartment_number" name="apartment_number" value="">
</div>
</div>
<div class="form-group
address-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Street Address </label>
<div class="col-sm-9">
<input type="text" class="form-control " maxlength="30" required="required" id="address" name="address" value="" aria-required="true">
</div>
</div>
<div class="form-group
address-2-form-group
">
<label class="col-sm-3 control-label text-right"> Street Address 2 </label>
<div class="col-sm-9">
<input type="text" class="form-control " maxlength="30" id="address_2" name="address_2" value="">
</div>
</div>
<div class="form-group
city-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> City </label>
<div class="col-sm-9">
<input type="text" class="form-control " maxlength="30" required="required" id="city" name="city" value="" aria-required="true">
</div>
</div>
<div class="form-group form-group-readonly subdivision-form-group required" aria-required="true">
<label class="col-sm-3 control-label text-right" data-original-name="
Province
">Province</label>
<div class="col-sm-9">
<select class="form-control subdivision " required="required" readonly="readonly" disabled="disabled" id="subdivision_readonly" name="subdivision_readonly" data-value="BC" aria-required="true">
<option value=""></option>
<option value="AB">Alberta</option>
<option value="BC" selected="selected">British Columbia</option>
<option value="MB">Manitoba</option>
<option value="NB">New Brunswick</option>
<option value="NL">Newfoundland and Labrador</option>
<option value="NT">Northwest Territories</option>
<option value="NS">Nova Scotia</option>
<option value="NU">Nunavut</option>
<option value="ON">Ontario</option>
<option value="PE">Prince Edward Island</option>
<option value="QC">Quebec</option>
<option value="SK">Saskatchewan</option>
<option value="YT">Yukon</option>
</select>
<input type="hidden" name="subdivision" id="subdivision" value="BC">
</div>
</div>
<div class="form-group postal-code-form-group required" aria-required="true">
<label class="col-sm-3 control-label text-right"> Postal Code </label>
<div class="col-sm-9">
<input type="text" class="form-control postal-code " maxlength="7" id="postal_code" name="postal_code" placeholder="___ ___" value="" aria-required="true" required="required">
</div>
</div>
<div class="form-group
form-group-readonly country-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Country </label>
<div class="col-sm-9">
<select class="form-control country " required="required" readonly="readonly" disabled="disabled" id="country_readonly" name="country_readonly" aria-required="true">
<option></option>
<option value="AF" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+93">Afghanistan</option>
<option value="AX" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+358">Åland</option>
<option value="AL" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+355">Albania</option>
<option value="DZ" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+213">Algeria</option>
<option value="AS" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+1684">American Samoa</option>
<option value="AD" data-postal-code-format="AD999" data-postal-code-regexp="^(?:AD)*(\d{3})$" data-phone-code="+376">Andorra</option>
<option value="AO" data-phone-code="+244">Angola</option>
<option value="AI" data-postal-code-format="AI-2640" data-postal-code-regexp="^(AI-2640)$" data-phone-code="+1264">Anguilla</option>
<option value="AQ" data-postal-code-format="7151" data-postal-code-regexp="^(7151)$" data-phone-code="+0">Antarctica</option>
<option value="AG" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+1268">Antigua and Barbuda</option>
<option value="AR" data-postal-code-format="A9999AAA" data-postal-code-regexp="^([A-Z]\d{4}[A-Z]{3})|([A-Z]\d{4})$" data-phone-code="+54">Argentina</option>
<option value="AM" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+374">Armenia</option>
<option value="AW" data-postal-code-format="0000 AW" data-postal-code-regexp="^(0000 AW)$" data-phone-code="+297">Aruba</option>
<option value="AU" data-subdivision-name="State" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+61">Australia</option>
<option value="AT" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+43">Austria</option>
<option value="AZ" data-postal-code-format="AZ 9999" data-postal-code-regexp="^(AZ) (\d{4})$" data-phone-code="+994">Azerbaijan</option>
<option value="BS" data-phone-code="+1242">Bahamas</option>
<option value="BH" data-postal-code-format="9999" data-postal-code-regexp="^(\d{3}\d?)$" data-phone-code="+973">Bahrain</option>
<option value="BD" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+880">Bangladesh</option>
<option value="BB" data-postal-code-format="BB99999" data-postal-code-regexp="^(?:BB)*(\d{5})$" data-phone-code="+1246">Barbados</option>
<option value="BY" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+375">Belarus</option>
<option value="BE" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+32">Belgium</option>
<option value="BZ" data-phone-code="+501">Belize</option>
<option value="BJ" data-phone-code="+229">Benin</option>
<option value="BM" data-postal-code-format="AA 99" data-postal-code-regexp="^([A-Z]{2} \d{2})$" data-phone-code="+1441">Bermuda</option>
<option value="BT" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+975">Bhutan</option>
<option value="BO" data-phone-code="+591">Bolivia</option>
<option value="BQ" data-postal-code-format="0000 BQ" data-postal-code-regexp="^(0000 BQ)$" data-phone-code="+599">Bonaire</option>
<option value="BA" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+387">Bosnia and Herzegovina</option>
<option value="BW" data-phone-code="+267">Botswana</option>
<option value="BV" data-phone-code="+47">Bouvet Island</option>
<option value="BR" data-postal-code-format="99999-999" data-postal-code-regexp="^[0-9]{5}-[0-9]{3}$" data-phone-code="+55">Brazil</option>
<option value="IO" data-postal-code-format="BB9D 1ZZ" data-postal-code-regexp="^(BB9D 1ZZ)$" data-phone-code="+246">British Indian Ocean Territory</option>
<option value="VG" data-postal-code-format="VG1190" data-postal-code-regexp="^(VG11)[0-6][0]$" data-phone-code="+1284">British Virgin Islands</option>
<option value="BN" data-postal-code-format="AA9999" data-postal-code-regexp="^([A-Z]{2}\d{4})$" data-phone-code="+673">Brunei</option>
<option value="BG" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+359">Bulgaria</option>
<option value="BF" data-phone-code="+226">Burkina Faso</option>
<option value="BI" data-phone-code="+257">Burundi</option>
<option value="KH" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+855">Cambodia</option>
<option value="CM" data-phone-code="+237">Cameroon</option>
<option value="CA" selected="selected" data-subdivision-name="Province" data-postal-code-format="A9A 9A9" data-postal-code-regexp="^(?![DFIOQU])[A-VXY][0-9][A-Z] +?[0-9][A-Z][0-9]$" data-phone-code="+1">Canada</option>
<option value="CV" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+238">Cape Verde</option>
<option value="KY" data-postal-code-format="KY9-9999" data-postal-code-regexp="^[K][Y][0-9]{1}[-]([0-9]){4}$" data-phone-code="+345">Cayman Islands</option>
<option value="CF" data-phone-code="+236">Central African Republic</option>
<option value="TD" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+235">Chad</option>
<option value="CL" data-postal-code-format="9999999" data-postal-code-regexp="^(\d{7})$" data-phone-code="+56">Chile</option>
<option value="CN" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+86">China</option>
<option value="CX" data-postal-code-format="6978" data-postal-code-regexp="^(6978)$" data-phone-code="+61">Christmas Island</option>
<option value="CC" data-postal-code-format="6799 W3" data-postal-code-regexp="^(6799 W3)$" data-phone-code="+61">Cocos Islands</option>
<option value="CO" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+57">Colombia</option>
<option value="KM" data-phone-code="+269">Comoros</option>
<option value="CK" data-phone-code="+682">Cook Islands</option>
<option value="CR" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+506">Costa Rica</option>
<option value="HR" data-postal-code-format="99999" data-postal-code-regexp="^(?:HR)*(\d{5})$" data-phone-code="+385">Croatia</option>
<option value="CU" data-postal-code-format="99999" data-postal-code-regexp="^(?:CP)*(\d{5})$" data-phone-code="+53">Cuba</option>
<option value="CW" data-postal-code-format="0000 CW" data-postal-code-regexp="^(0000 CW)$" data-phone-code="+599">Curacao</option>
<option value="CY" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+537">Cyprus</option>
<option value="CZ" data-postal-code-format="999 99" data-postal-code-regexp="^[0-9]{3} [0-9]{2}$" data-phone-code="+420">Czech Republic</option>
<option value="CD" data-phone-code="+243">Democratic Republic of the Congo</option>
<option value="DK" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+45">Denmark</option>
<option value="DJ" data-phone-code="+253">Djibouti</option>
<option value="DM" data-phone-code="+1767">Dominica</option>
<option value="DO" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+1809">Dominican Republic</option>
<option value="TL" data-phone-code="+670">East Timor</option>
<option value="EC" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+593">Ecuador</option>
<option value="EG" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+20">Egypt</option>
<option value="SV" data-postal-code-format="1101" data-postal-code-regexp="^(01101)$" data-phone-code="+503">El Salvador</option>
<option value="GQ" data-phone-code="+240">Equatorial Guinea</option>
<option value="ER" data-phone-code="+291">Eritrea</option>
<option value="EE" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+372">Estonia</option>
<option value="ET" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+251">Ethiopia</option>
<option value="FK" data-postal-code-format="FIQQ 1ZZ" data-postal-code-regexp="^(FIQQ 1ZZ)$" data-phone-code="+500">Falkland Islands</option>
<option value="FO" data-postal-code-format="999" data-postal-code-regexp="^(?:FO)*(\d{3})$" data-phone-code="+298">Faroe Islands</option>
<option value="FJ" data-phone-code="+679">Fiji</option>
<option value="FI" data-postal-code-format="99999" data-postal-code-regexp="^(?:FI)*(\d{5})$" data-phone-code="+358">Finland</option>
<option value="FR" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+33">France</option>
<option value="GF" data-postal-code-format="97399" data-postal-code-regexp="^((973)\d{2})$" data-phone-code="+594">French Guiana</option>
<option value="PF" data-postal-code-format="98799" data-postal-code-regexp="^((987)\d{2})$" data-phone-code="+689">French Polynesia</option>
<option value="TF" data-postal-code-format="98499" data-postal-code-regexp="^((984)\d{2})$" data-phone-code="+33">French Southern Territories</option>
<option value="GA" data-phone-code="+241">Gabon</option>
<option value="GM" data-phone-code="+220">Gambia</option>
<option value="GE" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+995">Georgia</option>
<option value="DE" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+49">Germany</option>
<option value="GH" data-phone-code="+233">Ghana</option>
<option value="GI" data-postal-code-format="GX11 1AA" data-postal-code-regexp="^(GX11 1AA)$" data-phone-code="+350">Gibraltar</option>
<option value="GR" data-postal-code-format="999 99" data-postal-code-regexp="^(\d{3}) \d{2}$" data-phone-code="+30">Greece</option>
<option value="GL" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+299">Greenland</option>
<option value="GD" data-phone-code="+1473">Grenada</option>
<option value="GP" data-postal-code-format="97199" data-postal-code-regexp="^((971)[0-9][0-0])$" data-phone-code="+590">Guadeloupe</option>
<option value="GU" data-postal-code-format="96999" data-postal-code-regexp="^((969)[1-3][0-2])$" data-phone-code="+1671">Guam</option>
<option value="GT" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+502">Guatemala</option>
<option value="GG" data-postal-code-format="GY9 9AA" data-postal-code-regexp="^((GY)([0-9][0-9A-HJKPS-UW]?|[A-HK-Y][0-9][0-9ABEHMNPRV-Y]?) [0-9][ABD-HJLNP-UW-Z]{2})$" data-phone-code="+44">Guernsey</option>
<option value="GN" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+224">Guinea</option>
<option value="GW" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+245">Guinea-Bissau</option>
<option value="GY" data-phone-code="+595">Guyana</option>
<option value="HT" data-postal-code-format="9999" data-postal-code-regexp="^(?:HT)*(\d{4})$" data-phone-code="+509">Haiti</option>
<option value="HM" data-postal-code-format="7151" data-postal-code-regexp="^(7151)$" data-phone-code="+672">Heard Island and McDonald Islands</option>
<option value="HN" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+504">Honduras</option>
<option value="HK" data-phone-code="+852">Hong Kong</option>
<option value="HU" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+36">Hungary</option>
<option value="IS" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+354">Iceland</option>
<option value="IN" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+91">India</option>
<option value="ID" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+62">Indonesia</option>
<option value="IR" data-postal-code-format="99999" data-postal-code-regexp="^\d{5}([\-]\d{5})?$" data-phone-code="+98">Iran</option>
<option value="IQ" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+964">Iraq</option>
<option value="IE" data-phone-code="+353">Ireland</option>
<option value="IM" data-postal-code-format="IM99 9AA" data-postal-code-regexp="^((IM)([0-9][0-9A-HJKPS-UW]?|[A-HK-Y][0-9][0-9ABEHMNPRV-Y]?) [0-9][ABD-HJLNP-UW-Z]{2})$" data-phone-code="+44">Isle of Man</option>
<option value="IL" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+972">Israel</option>
<option value="IT" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+39">Italy</option>
<option value="CI" data-phone-code="+225">Ivory Coast</option>
<option value="JM" data-postal-code-format="JMAAA99" data-postal-code-regexp="^((JM)[A-Z]{3,3}\d{2,2})$" data-phone-code="+1876">Jamaica</option>
<option value="JP" data-postal-code-format="999-9999" data-postal-code-regexp="^(\d{3}-\d{4})$" data-phone-code="+81">Japan</option>
<option value="JE" data-postal-code-format="JE9 9AA" data-postal-code-regexp="^(JE)([0-9]\d{1})$" data-phone-code="+44">Jersey</option>
<option value="JO" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+962">Jordan</option>
<option value="KZ" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+77">Kazakhstan</option>
<option value="KE" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+254">Kenya</option>
<option value="KI" data-phone-code="+686">Kiribati</option>
<option value="XK" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+383">Kosovo</option>
<option value="KW" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+965">Kuwait</option>
<option value="KG" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+996">Kyrgyzstan</option>
<option value="LA" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+856">Laos</option>
<option value="LV" data-postal-code-format="LV-9999" data-postal-code-regexp="^[L]{1}[V]{1}[-]([0-9]){4}$" data-phone-code="+371">Latvia</option>
<option value="LB" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4}(\d{4})?)$" data-phone-code="+961">Lebanon</option>
<option value="LS" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+266">Lesotho</option>
<option value="LR" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+231">Liberia</option>
<option value="LY" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+218">Libya</option>
<option value="LI" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+423">Liechtenstein</option>
<option value="LT" data-postal-code-format="99999" data-postal-code-regexp="^(?:LT)*(\d{5})$" data-phone-code="+370">Lithuania</option>
<option value="LU" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+352">Luxembourg</option>
<option value="MO" data-phone-code="+853">Macao</option>
<option value="MK" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+389">Macedonia</option>
<option value="MG" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+261">Madagascar</option>
<option value="MW" data-phone-code="+265">Malawi</option>
<option value="MY" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+60">Malaysia</option>
<option value="MV" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+960">Maldives</option>
<option value="ML" data-phone-code="+223">Mali</option>
<option value="MT" data-postal-code-format="AAA 9999" data-postal-code-regexp="^[A-Z]{3} [0-9]{4}$" data-phone-code="+356">Malta</option>
<option value="MH" data-postal-code-format="96999" data-postal-code-regexp="^((969)[6-7][0-9])$" data-phone-code="+692">Marshall Islands</option>
<option value="MQ" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+596">Martinique</option>
<option value="MR" data-phone-code="+222">Mauritania</option>
<option value="MU" data-postal-code-format="A9999" data-postal-code-regexp="^([0-9A-Z]\d{4})$" data-phone-code="+230">Mauritius</option>
<option value="YT" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+262">Mayotte</option>
<option value="MX" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+52">Mexico</option>
<option value="FM" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+691">Micronesia</option>
<option value="MD" data-postal-code-format="9999" data-postal-code-regexp="^(?:MD)*(\d{4})$" data-phone-code="+373">Moldova</option>
<option value="MC" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+377">Monaco</option>
<option value="MN" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+976">Mongolia</option>
<option value="ME" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+382">Montenegro</option>
<option value="MS" data-phone-code="+1664">Montserrat</option>
<option value="MA" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+212">Morocco</option>
<option value="MZ" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+258">Mozambique</option>
<option value="MM" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+95">Myanmar</option>
<option value="NA" data-phone-code="+264">Namibia</option>
<option value="NR" data-phone-code="+674">Nauru</option>
<option value="NP" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+977">Nepal</option>
<option value="NL" data-postal-code-format="9999 AA" data-postal-code-regexp="^[0-9]{4} [A-Z]{2}$" data-phone-code="+31">Netherlands</option>
<option value="NC" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+687">New Caledonia</option>
<option value="NZ" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+64">New Zealand</option>
<option value="NI" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+505">Nicaragua</option>
<option value="NE" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+227">Niger</option>
<option value="NG" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+234">Nigeria</option>
<option value="NU" data-phone-code="+683">Niue</option>
<option value="NF" data-postal-code-format="2899" data-postal-code-regexp="^(2899)$" data-phone-code="+672">Norfolk Island</option>
<option value="KP" data-phone-code="+850">North Korea</option>
<option value="MP" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+1670">Northern Mariana Islands</option>
<option value="NO" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+47">Norway</option>
<option value="OM" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+968">Oman</option>
<option value="PK" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+92">Pakistan</option>
<option value="PW" data-postal-code-format="96940" data-postal-code-regexp="^(96940)$" data-phone-code="+680">Palau</option>
<option value="PS" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+970">Palestine</option>
<option value="PA" data-phone-code="+507">Panama</option>
<option value="PG" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+675">Papua New Guinea</option>
<option value="PY" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+595">Paraguay</option>
<option value="PE" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+51">Peru</option>
<option value="PH" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+63">Philippines</option>
<option value="PN" data-postal-code-format="PCR9 1ZZ" data-postal-code-regexp="^(PCR9 1ZZ)$" data-phone-code="+672">Pitcairn Islands</option>
<option value="PL" data-subdivision-name="Voivodeship" data-postal-code-format="99-999" data-postal-code-regexp="^[0-9]{2}[-]([0-9]){3}$" data-phone-code="+48">Poland</option>
<option value="PT" data-postal-code-format="9999-999" data-postal-code-regexp="^\d{4}((-|\s)?\d{3})?$" data-phone-code="+351">Portugal</option>
<option value="PR" data-postal-code-format="99999" data-postal-code-regexp="^\d{5}((-|\s)?\d{4})?$" data-phone-code="+1787">Puerto Rico</option>
<option value="QA" data-phone-code="+974">Qatar</option>
<option value="CG" data-phone-code="+242">Republic of the Congo</option>
<option value="RE" data-postal-code-format="99999" data-postal-code-regexp="^[9]{1}[7|8][4|7|8]\d{2}$" data-phone-code="+262">Réunion</option>
<option value="RO" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+40">Romania</option>
<option value="RU" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+7">Russia</option>
<option value="RW" data-phone-code="+250">Rwanda</option>
<option value="BL" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+590">Saint Barthélemy</option>
<option value="SH" data-postal-code-format="AAAA 1ZZ" data-postal-code-regexp="^[A-Z]{4} (1ZZ)$" data-phone-code="+290">Saint Helena</option>
<option value="KN" data-phone-code="+1869">Saint Kitts and Nevis</option>
<option value="LC" data-phone-code="+1758">Saint Lucia</option>
<option value="MF" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+1">Saint Martin</option>
<option value="PM" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+33">Saint Pierre and Miquelon</option>
<option value="VC" data-postal-code-format="VC9999" data-postal-code-regexp="^(VC)(\d{4})$" data-phone-code="+1784">Saint Vincent and the Grenadines</option>
<option value="WS" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+685">Samoa</option>
<option value="SM" data-postal-code-format="99999" data-postal-code-regexp="^(4789\d)$" data-phone-code="+378">San Marino</option>
<option value="ST" data-phone-code="+239">São Tomé and Príncipe</option>
<option value="SA" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+966">Saudi Arabia</option>
<option value="SN" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+221">Senegal</option>
<option value="RS" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+381">Serbia</option>
<option value="SC" data-phone-code="+248">Seychelles</option>
<option value="SL" data-phone-code="+232">Sierra Leone</option>
<option value="SG" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+65">Singapore</option>
<option value="SX" data-postal-code-format="0000 AA" data-postal-code-regexp="^(0000 AA)$" data-phone-code="+1">Sint Maarten</option>
<option value="SK" data-postal-code-format="999 99" data-postal-code-regexp="^(\d{3} \d{2})$" data-phone-code="+421">Slovakia</option>
<option value="SI" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+386">Slovenia</option>
<option value="SB" data-phone-code="+677">Solomon Islands</option>
<option value="SO" data-phone-code="+252">Somalia</option>
<option value="ZA" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+27">South Africa</option>
<option value="GS" data-postal-code-format="SIQQ 1ZZ" data-postal-code-regexp="^(SIQQ 1ZZ)$" data-phone-code="+500">South Georgia and the South Sandwich Islands</option>
<option value="KR" data-postal-code-format="999-999" data-postal-code-regexp="^(\d{3}[-]\d{3})$" data-phone-code="+82">South Korea</option>
<option value="SS" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+249">South Sudan</option>
<option value="ES" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+34">Spain</option>
<option value="LK" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+94">Sri Lanka</option>
<option value="SD" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+249">Sudan</option>
<option value="SR" data-phone-code="+597">Suriname</option>
<option value="SJ" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+47">Svalbard and Jan Mayen</option>
<option value="SZ" data-postal-code-format="A999" data-postal-code-regexp="^([A-Z]\d{3})$" data-phone-code="+268">Swaziland</option>
<option value="SE" data-postal-code-format="999 99" data-postal-code-regexp="^(\d{3} \d{2})$" data-phone-code="+46">Sweden</option>
<option value="CH" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+41">Switzerland</option>
<option value="SY" data-phone-code="+963">Syria</option>
<option value="TW" data-postal-code-format="999 99" data-postal-code-regexp="^(\d{3} \d{2})|(\d{3})$" data-phone-code="+886">Taiwan</option>
<option value="TJ" data-postal-code-format="999" data-postal-code-regexp="^(\d{3})$" data-phone-code="+992">Tajikistan</option>
<option value="TZ" data-phone-code="+255">Tanzania</option>
<option value="TH" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+66">Thailand</option>
<option value="TG" data-phone-code="+228">Togo</option>
<option value="TK" data-phone-code="+690">Tokelau</option>
<option value="TO" data-phone-code="+676">Tonga</option>
<option value="TT" data-phone-code="+1868">Trinidad and Tobago</option>
<option value="TN" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+216">Tunisia</option>
<option value="TR" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+90">Turkey</option>
<option value="TM" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+993">Turkmenistan</option>
<option value="TC" data-postal-code-format="TKCA 1ZZ" data-postal-code-regexp="^(TKCA 1ZZ)$" data-phone-code="+1649">Turks and Caicos Islands</option>
<option value="TV" data-phone-code="+688">Tuvalu</option>
<option value="UM" data-phone-code="+1">U.S. Minor Outlying Islands</option>
<option value="VI" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+1340">U.S. Virgin Islands</option>
<option value="UG" data-phone-code="+256">Uganda</option>
<option value="UA" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+380">Ukraine</option>
<option value="AE" data-phone-code="+971">United Arab Emirates</option>
<option value="GB" data-postal-code-format="AA9A 9AA|A9A 9AA|A9 9AA|A99 9AA|AA9 9AA|AA99 9AA"
data-postal-code-regexp="^(((([A-PR-UWYZ][0-9][0-9A-HJKS-UW]?)|([A-PR-UWYZ][A-HK-Y][0-9][0-9ABEHMNPRV-Y]?))\s{0,2}[0-9]([ABD-HJLNP-UW-Z]{2}))|(GIR\s{0,2}0AA))$" data-phone-code="+44">United Kingdom</option>
<option value="US" data-subdivision-name="State" data-postal-code-format="99999-9999" data-postal-code-regexp="^\d{5}([\-]\d{4})?$" data-phone-code="+1">United States</option>
<option value="UY" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+598">Uruguay</option>
<option value="UZ" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+998">Uzbekistan</option>
<option value="VU" data-phone-code="+678">Vanuatu</option>
<option value="VA" data-postal-code-format="120" data-postal-code-regexp="^(120)$" data-phone-code="+264">Vatican City</option>
<option value="VE" data-postal-code-format="9999" data-postal-code-regexp="^(\d{4})$" data-phone-code="+58">Venezuela</option>
<option value="VN" data-postal-code-format="999999" data-postal-code-regexp="^(\d{6})$" data-phone-code="+84">Vietnam</option>
<option value="WF" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+681">Wallis and Futuna</option>
<option value="EH" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+212">Western Sahara</option>
<option value="YE" data-phone-code="+967">Yemen</option>
<option value="ZM" data-postal-code-format="99999" data-postal-code-regexp="^(\d{5})$" data-phone-code="+260">Zambia</option>
<option value="ZW" data-phone-code="+263">Zimbabwe</option>
</select>
<input type="hidden" name="country" id="country" value="CA">
</div>
</div>
<div class="form-group
email-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> E-mail </label>
<div class="col-sm-9">
<input type="email" class="form-control " maxlength="150" required="required" id="email" name="email" value="" aria-required="true">
</div>
</div>
<div class="form-group
email-confirmation-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Re-Enter Your Email </label>
<div class="col-sm-9">
<input type="email" class="form-control " maxlength="150" required="required" id="email_confirmation" name="email_confirmation" value="" aria-required="true">
</div>
</div>
<div class="form-group
raffle-nexus-newletter-form-group
">
<label class="col-sm-3 control-label text-right">
</label>
<div class="col-sm-9">
<div class="checkbox">
<label>
<input class=" " type="checkbox" id="raffle_nexus_newletter" name="raffle_nexus_newletter" value="Y"> Sign up for the Raffle Nexus newsletter </label>
</div>
</div>
</div>
<div class="form-group
day-phone-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Day Phone </label>
<div class="col-sm-9">
<div id="day_phone_direct" class="phone-code" data-country-code="CA" data-phone-code="+1" style=""><img class="flag" src="/images/flags/ca.png" width="16" height="11"> </div>
<input type="hidden" name="day_phone_phone_code" id="day_phone_phone_code" value="+1">
<input type="text" class="form-control phone-number " maxlength="20" required="required" id="day_phone" name="day_phone" placeholder="" value="" aria-required="true" style="padding-left: 40px;">
<div class="checkbox"><label style=" font-weight: normal;"><input type="checkbox" value="" id="day_phone_as_cellular">Day Phone is my Cellular Phone</label></div>
</div>
</div>
<div class="form-group
evening-phone-form-group
">
<label class="col-sm-3 control-label text-right"> Evening Phone </label>
<div class="col-sm-9">
<div id="evening_phone_direct" class="phone-code" data-country-code="CA" data-phone-code="+1" style=""><img class="flag" src="/images/flags/ca.png" width="16" height="11"> </div>
<input type="hidden" name="evening_phone_phone_code" id="evening_phone_phone_code" value="+1">
<input type="text" class="form-control phone-number " maxlength="20" id="evening_phone" name="evening_phone" placeholder="" value="" style="padding-left: 40px;">
</div>
</div>
<div class="form-group
cellular-phone-form-group
">
<label class="col-sm-3 control-label text-right"> Cellular Phone </label>
<div class="col-sm-9">
<div id="cellular_phone_direct" class="phone-code" data-country-code="CA" data-phone-code="+1" style=""><img class="flag" src="/images/flags/ca.png" width="16" height="11"> </div>
<input type="hidden" name="cellular_phone_phone_code" id="cellular_phone_phone_code" value="+1">
<input type="text" class="form-control phone-number " maxlength="20" id="cellular_phone" name="cellular_phone" placeholder="" value="" style="padding-left: 40px;">
</div>
</div>
<div class="form-group
text-updates-form-group
">
<label class="col-sm-3 control-label text-right">
</label>
<div class="col-sm-9">
<div class="checkbox disabled">
<label>
<input class="disabled" type="checkbox" id="text_updates" name="text_updates" value="Y" disabled=""> Sign up for text alerts (must provide cellular phone number) </label>
</div>
</div>
</div>
</div>
</div>
<div class="hpanel hblue form-horizontal" id="field_group_credit_card">
<div class="panel-heading"> Credit Card Information </div>
<div class="panel-body">
<p> VISA, MasterCard and American Express accepted. </p>
<input type="hidden" name="cc_token" id="cc_token" value="">
<input type="hidden" name="cc_last4" id="cc_last4" value="">
<div class="form-group
cc-type-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right">
</label>
<div class="col-sm-9">
<input type="hidden" class="form-control credit-card-type" id="cc_type" name="cc_type" value="">
</div>
</div>
<div class="form-group
cc-number-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Credit Card Number </label>
<div class="col-sm-9">
<div id="cc-number-bambora" class="bambora-checkoutfield-empty form-control"><iframe
src="https://libs.na.bambora.com/customcheckout/1.0.3/iframe.html?type=card-number&source=https%3A%2F%2Ftickets.nanaimohospice.com%2F&origin=https%3A%2F%2Ftickets.nanaimohospice.com" scrolling="no" height="18px" width="100%"
name="bambora-card-number-iframe" style="border: none; overflow: visible; background-color: transparent;"></iframe></div>
</div>
</div>
<div class="form-group
cc-expires-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Expire ends </label>
<div class="col-sm-9">
<div id="cc-expires-bambora" class="bambora-checkoutfield-empty form-control"><iframe
src="https://libs.na.bambora.com/customcheckout/1.0.3/iframe.html?type=expiry&source=https%3A%2F%2Ftickets.nanaimohospice.com%2F&origin=https%3A%2F%2Ftickets.nanaimohospice.com" scrolling="no" height="18px" width="100%"
name="bambora-expiry-iframe" style="border: none; overflow: visible; background-color: transparent;"></iframe></div>
</div>
</div>
<div class="form-group
cc-cvv-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> CVV/CVC <span class="fa-stack fa-lg cvv-info-icon" data-original-title="" title=""><i class="fa fa-square fa-stack-2x"></i><i class="fa fa-info fa-stack-1x fa-inverse"></i></span>
</label>
<div class="col-sm-9">
<div id="cc-cvv-bambora" class="bambora-checkoutfield-empty form-control"><iframe
src="https://libs.na.bambora.com/customcheckout/1.0.3/iframe.html?type=cvv&source=https%3A%2F%2Ftickets.nanaimohospice.com%2F&origin=https%3A%2F%2Ftickets.nanaimohospice.com" scrolling="no" height="18px" width="100%"
name="bambora-cvv-iframe" style="border: none; overflow: visible; background-color: transparent;"></iframe></div>
</div>
</div>
<div class="form-group
cc-holder-form-group
required
" aria-required="true">
<label class="col-sm-3 control-label text-right"> Name on Card </label>
<div class="col-sm-9">
<input type="text" class="form-control " required="required" id="cc_holder" name="cc_holder" value="" aria-required="true">
</div>
</div>
</div>
</div>
<div class="hpanel hblue" id="order-summary">
<div class="panel-heading">Summary</div>
<div class="panel-body">
<div class="row">
<div class="form-group">
<label class="col-sm-3 control-label text-right"><strong>Home Lottery</strong></label>
<div class="col-sm-9">
<span class="control-label font-bold" id="sum_qty_A">No tickets selected.</span>
<span class="control-label" id="sum_text_A"></span>
</div>
</div>
</div>
<div class="row">
<div class="form-group">
<label class="col-sm-3 control-label text-right"><strong>50/50</strong></label>
<div class="col-sm-9">
<span class="control-label font-bold" id="sum_qty_B">No tickets selected.</span>
<span class="control-label" id="sum_text_B"></span>
</div>
</div>
</div>
<div class="row">
<div class="form-group">
<label class="col-sm-3 control-label text-right"><strong>WestJet Ticket Raffle</strong></label>
<div class="col-sm-9">
<span class="control-label font-bold" id="sum_qty_C">No tickets selected.</span>
<span class="control-label" id="sum_text_C"></span>
</div>
</div>
</div>
<div class="row">
<div class="form-group">
<label class="col-sm-3 control-label text-right">
<h2>Grand Total</h2>
</label>
<div class="col-sm-8">
<h2 class="control-label grand_total" data-value="0">$0</h2>
</div>
</div>
</div>
<div id="autofill-prompt" class="well bg-danger"> We've detected that autofill may have been used on the order form. Please <a href="#" id="autofill-prompt-link">review your order</a> before continuing. </div>
</div>
</div>
<button type="submit" id="place-order-button" class="pull-left btn btn-primary btn-lg">Place Order</button>
<a href="https://nanaimohospice.com/" class="pull-right btn btn-lg">Back to lottery website</a>
<div class="clearfix"></div>
</form>Text Content
ORDER TICKETS FOR THE 2021 DREAM HOME LOTTERY WestJet Draw deadline in 43 days, 23 hours, 24 minutes Tickets may be sold and purchased in British Columbia only. Orders will not be accepted via the Internet from anyone outside of British Columbia or any non-residents of British Columbia. Eligibility Confirmation I am 19 years of age or older. I am in the Province of British Columbia when placing this order. I have read and agree to the Terms of Use and Rules of Play. Home Lottery Single Ticket Amount − + x $100.00 5-Ticket Pack Amount − + x $400.00 Tickets quantity: No tickets selected. BC Gaming Event Licence #128993 50/50 Current 50/50 Jackpot $122,400 Winner takes half Single Ticket Amount − + x $25.00 5-Ticket Pack Amount − + x $100.00 Tickets quantity: No tickets selected. BC Gaming Event Licence #129003 WestJet Ticket Raffle Single Ticket Amount − + x $25.00 Tickets quantity: No tickets selected. BC Gaming Event Licence #129603 Grand Total $0 All fields in 'bold' are required. Contact Information First Name Last Name Apartment/Unit # Street Address Street Address 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Country Afghanistan Åland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Réunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe E-mail Re-Enter Your Email Sign up for the Raffle Nexus newsletter Day Phone Day Phone is my Cellular Phone Evening Phone Cellular Phone Sign up for text alerts (must provide cellular phone number) Credit Card Information VISA, MasterCard and American Express accepted. Credit Card Number Expire ends CVV/CVC Name on Card Summary Home Lottery No tickets selected. 50/50 No tickets selected. WestJet Ticket Raffle No tickets selected. GRAND TOTAL $0 We've detected that autofill may have been used on the order form. Please review your order before continuing. Place Order Back to lottery website Powered by Chances are 1 in 25,000 (total tickets for sale) to win the Dream Home Lottery prize. BC Gaming Event Licence #128993 Chances are 1 in 50,000 (total tickets for sale) to win the 50/50 prize. BC Gaming Event Licence #129003 Chances are 1 in 10,000 (total tickets for sale) to win the WestJet Ticket Raffle prize. BC Gaming Event Licence #129603 Know your limit, play within it Problem Gambling Help Line 1-888-795-6111 www.bcresponsiblegambling.ca 19+ to play