Senior Individual Membership
Junior (Honorary) Membership
Method of Payment:
o Cash _____________________________________________________
o Check – Check # ____________________________________________
o Money Order – MO# _______________________________________
o I wish to have my membership status listed on Pet Helpers Incorporated’s web site.
o I do not wish to have my membership status listed on Pet Helpers Incorporated’s web site.
Member Information:
Name: _____________________________________________________________________________________
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Company Name: ________________________________________________________________________________ Address: _______________________________________________________________________________________
City_________________________________________ State: _____________________ Zip: _______________ Telephone Home _____________________Cellular____________________Office___________________Ext______
E-Mail1______________________________________E-Mail #2___________________________________________
Web Address: __________________________________________ Date of Birth: _______________________(MM-DD-YY)
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Signature: __________________________________________ Date: ____________________
Accounting Department Use Only:
Member #: __________________________________________ | Class: _______________________________________________ |
Authorization #: ___________________________________ | Date: ________-________-________ (MM-DD-YYYY) |