Donation Form; Please Mail to: Roice-Hurst Humane Society * 3320 D 1/2 Road Clifton CO, 81520*

I would like to make a donation to the Roice-Hurst Humane Society in the amount of:
$25 ____ $50 ____ $75 ____ $100 ____$200 ____ $500 ____Other $ ___________

Check: ____ Credit Card ____

This donation is:
A Membership Donation: ____ A general donation: ____ In Honor of a Pet: ____
In Honor of a Person: ____ In Memory of a Pet: ____ In Memory of a Person: ____

Optional: Name of Pet or Person honored/memorialized: _____________________________________

Please provide the following billing information:

Name: ____________________________ Address: ____________________________Apt/Init______

City: ____________________________ State: _______________________ Zip: ________________

Phone Number ____________________________ Email ____________________________________

Credit Card Information

Type: Visa ____ MasterCard ____ Card Number: _______________________________________

Expiration Date: ________________________ Signature ____________________________________

Is there anything else you would like us to know about your donation? Please enter your comments below (please
limit your comments to Humane Society related information only)
____________________________________________________________________________________

Donation given anonymously: ____

Please choose one of the following:

____ Please send a thank you letter for this donation, which will serve as my receipt.
____ I would like to waive my membership benefits. Please send a thank you letter which will serve as my receipt.
____ I would like to waive my membership benefits. No thank you is necessary, my check will serve as my receipt.