I want to help those animals in need, both today and in the future. Please count me in as a member of A.D.O.P.T.
Name:_______________________________________________________________
Street Address:________________________________________________________
Your Membership Choice City:___________________________ State: _________ Zip Code:______________
Individual $39 ________ Phone #:_____________________Email:___________________________________
Family $79 ________ I would also like to include a GIFT membership for the following individual / family:
Shelter Friend $149 ________ Name:_______________________________________________________________
Individual – Gift $39 ________ Family – Gift ________ Street Address:________________________________________________________
City:___________________________ State: _________ Zip Code:______________
$79 Phone #:_____________________Email:___________________________________
Additional Donation ________ (Recipient of gift membership will receive acknowledgement certificate of membership)
Total Enclosed ________ ____My check is enclosed
____Please charge my credit card (Visa / Mastercard)
Name on Card:______________________________________________________
Card Number:_______________________________________ Exp. Date:______
Signature:__________________________________________________________
Please circle your choice of membership, enclose this form along with check written to A.D.O.P.T. and mail to:
A.D.O.P.T. - MEMBERSHIPS
420 Industrial Dr. Naperville, IL 60563