Lynchburg Humane Society Donation Form

Please print out this form and mail it to:
Lynchburg Humane Society
3305 Naval Reserve Road
Lynchburg, VA  24501
Thank you for your generosity!

You can also click on title to open document in MS word.

Name: ____________________________________________ Phone Number: __________________

Address: __________________________________________

    __________________________________________

E-Mail:    __________________________________________

Desired Contribution Level: (please circle)

$25
$50
$100
$500
Other $ ________

Does your employer match your contribution? (please circle) Y / N

Employer's Name: ____________________________________________________________________

Is this gift in memory of or in honor of someone? (please circle) Y / N  If so, please write the name below:

_____________________________________________

If yes, please provide the name and address of the individual(s) who should receive acknowledgement of the gift.

_____________________________________________

_____________________________________________

_____________________________________________

Would you like for the person to know the amount of your gift?  (please circle) Y / N

Please make your check payable to the Lynchburg Humane Society.

o Please charge my donation to my credit card  o Visa  o Mastercard 

Card number _________________________________________ Exp. Date ______________________

Signature _______________________________________________________