10/01/12

Date_________________

Last Name________________________________________

First Name(s)____________________________________________________________________________________

Address________________________________________________________________________________________

City___________________________________________________ State________ Zip__________

Phone_________________________ Cell Phone________________________ Email___________________________

Please indicate if you would be willing to help with any of the following:

Fund-raising__

Yard Sale___

Other (specify)____________________________________________________________________________

Enclosed:

Family Membership $20.00 ____________

Donation Amount __________ In memory of _________________________________

The Humane Society of Washington County is a 501 c3 no-profit organization. All donations are tax deductable.

Mail to:

Humane Society of Washington County

204 W. Joseph St.

Salem, IN 47167

Support the Humane Society of Washington County by buyng pet supplies from Pet Meds.