Yes, I Want to Help!

I would like to join the Placencia Humane Society in the following membership category (please check one):

Student (under 16) US$  5/year
Individual US$ 10/year
Family (2-5 persons) US$ 15/year
Patron US$ 50/year
Benefactor US$500/life membership

I am joining as a Patron or Benefactor, and my T-shirt size is _______ (Please allow 3-4 weeks for delivery of your T-shirt.)  (A free T-shirt is available only with initial new membership)

My Membership Information:

Name:________________________________________________

Street Address:________________________________________

State/Province/District:_______________Zip Code:_________

Email address:________________________________________

Home Telephone:______________________________________

In addition to my membership, I would like to help by:

 Volunteering, please contact me

 Donating additional funds of ___________

 Donating animal care products (please contact me)

Form of Payment:

 My personal check is enclosed

 A credit card authorization has been emailed

Personal checks should be mailed to The Placencia Humane Society, General Delivery, Placencia, Belize or dropped off at the Placencia Tourism Center  in Placencia Village