MEMORIAL/HONORARY DONATION FORM

Donor’s Name ______________________________________________

Address ___________________________________________________

City _____________________________ State ______ Zip ___________

Phone_____________________________________________________

The donation is a gift:

 In memory of (name of person) ________________________________

 In memory of (name of pet and type) ____________________________

ð In honor of (name of person) __________________________________

for:

ð Birthday ð Holiday

ð Anniversary ð Retirement

ð Graduation ð Other _________________

Payment:  Check enclosed Credit Card:  MC  VISA

Donation Amount ______________

Credit Card Number____________________________________________

Expiration Date _______________________________________________

Signature ____________________________________________________

NOTIFICATION

Please send a mail notification regarding my donation to:

Name ______________________________________________________

Address_____________________________________________________

City ________________________ State _______ Zip ________________

Phone ______________________________________________________

Please send this form to:

CGHS/SPCA

125 Humane Society Road

Hudson, NY 12534