Humane Society of Washington County Membership Application

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__

Posters/Art work__ Yard Sale__

Auction__

Other (specify)____________________________________________________________________________

Enclosed:

Membership $10.00 per person____________

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

P.O. Box 51

Salem, IN 47167