| Please Inidicate All That Apply |
| Membership |
| Individual |
 |
$20 |
 |
____ |
 |
Family |
 |
$35 |
 |
____ |
| Jr. (under 18) |
 |
$5 |
 |
____ |
 |
Pet |
 |
$2 |
 |
____ |
| Dog Lover |
 |
$50 |
 |
____ |
 |
Cat Lover |
 |
$50 |
 |
____ |
| Business |
 |
$100 |
 |
____ |
 |
Pet Fanatic |
 |
$150 |
 |
____ |
| MDHS Builder |
 |
$500 |
 |
____ |
 |
Lifetime Member |
 |
$1,000 - $1,999 |
 |
____ |
| Lifetime Benefactor |
 |
$2,000 - $4,999 |
 |
____ |
 |
Lifetime Leader of the Patk |
 |
$5,000 or more |
 |
____ |
 |
| Donations |
| Donation only |
 |
$____________ |
 |
Memorial |
 |
$____________ |
 |
| ____ Check here if you wish to be a Hush Puppy (Anonymous) |
 |
| Volunteer |
| I am interested in helping in the following areas: |
| ____Membership |
 |
____Administration |
 |
____Education |
 |
____Fund Raising |
| ____Public Relations |
 |
____Foster Home Program |
 |
____Animal Shelter |
 |
|
|
 |
| Contact Information |
| Name |
 |
__________________________________________ |
| Address |
 |
__________________________________________ |
| Phone |
 |
(H)_________________
(W)_________________ |
|
 |
Please send this form with your tax deductible donation to:
MonDak Humane Society, PO Box 1572, Williston, ND 58802
|