Humane Society of Inland Mendocino County - Donation Member Registration Form

Member Registration

Name:

Address:

City:

State:

Zip:

Email:

I would like to make a cash contribution $_______

I would like to be a member of HSIMC:

___ ___	New Membership Renewal of current membership
___ ___ ___ ___ ___	Patron Business Individual Family Student / Senior	$100 $75 $35 $50 $20
___	Please send your newsletters and announcements to my street address
___	Please send your newsletters and/or announcements to my email address

All donations, including those for membership, are tax deductible. Please send your check along with the above form to:

Humane Society for Inland Mendocino County
9700 Uva Drive
Redwood Valley, CA 95470

Phone (707)485-0123
Fax (707)468-1197