Humane Society of Lackawanna County

Memorial/ Honor Gifts Form

Date_________

Is this gift in Honor or in Memory of the person or animal named below?____________

This Donation is made in the name of __________________________

Donor Name ____________________________________________

Donor Address ___________________________________________

_______________________________________________________

Donor Phone Number _______________

Amount of Gift _____________

Donation submitted with this form?_________ Donation Submitted Through Paypal? __________

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Gift Acknowledgement to be sent to:

Name_____________________________

Address ___________________________________________________________________

Please Mail this Form to:

The Humane Society of Lackawanna County
967 Griffin Pond Rd
Clarks Summit PA 18411

Questions? 585-0516