NAME:________________________________________________________________________

ADDRESS:_____________________________________________________________________

CITY:_________________________________________________________________________

STATE:___________________ ZIP:____________

HOME PHONE:________________________BUSINESS PHONE:______________________

EMAIL:____________________________________________________________

AMOUNT ENCLOSED:_____________

IS THIS DONATION A GIFT IN SOMEONE'S HONOR? IF SO, PLEASE PROVIDE:

FIRST AND LAST NAME:________________________________________________________

RELATION TO YOU:____________________________________________________________

DO YOU WANT US TO SEND A CARD TELLING THEM ABOUT THE DONATION? [ ] YES [ ] NO

ADDRESS: ______________________________________________________________________

________________________________________________________________________________

ANY SPECIAL MESSAGE?
________________________________________________________________________________

Please mail to:
Central Rescue and Rehabilitation
PO Box 79
Wales, MA 01081