DONATION FORM

CGHS/SPCA

Name _____________________________________

Address ___________________________________

City ________________ State ______ Zip _______

Phone __________________ Date _____________

Donation Amount  $ _________________________

 Check or money order payable to CGHS/SPCA

Credit Card    Visa    MasterCard

Credit Card Number _________________________

Expiration Date _____________________________

Signature __________________________________

Please send this form to:

CGHS/SPCA

125 Humane Society Road

Hudson, NY 12534

Thank you.