$15 ____ $25 ____ $50 ____ $100 ____ $250 ____ $500 ____

other $______

Date: ___________________________________

My name:________________________________

Address:_________________________________

City:____________________________________

Province/State:_______

Zip/Postal:_______________________________

Daytime Telephone: _______________________

Email address: ___________________________

Does your company have a match donations program? ______, If so, who do you work for?

 ___________________________________________________________________________

If this is a memorial gift, please provide the following information:

This gift is in memory of: _______________________________________________________

______ Pet ______ Person

Method of Donation:

_____ I have enclosed a check or money order, payable to the BC CHIHUAHUA RESCUE

The BC Chihuahua Rescue thanks you for your help!