I want to become a member of Virginia Voters for Animal Welfare. Cost of Membership is $5


Membership                                    $                   5.00


Contribution                                    $                           


Total Amount of Check                    $                           

Member information:

Date: _______________________________

First Name: ________________ MI: ____ Last Name:________________________

Physical Address: _____________________________________________________________

City: ______________________________ State: ______  ZIP:_______________

Mailing Address: _______________________________________________________

City: _____________________________ State: ______ ZIP:___________________

Email:________________________________________________________________

Home Phone: ____________________________

Work Phone: _____________________________

Cell Phone: _______________________________

To what other animal groups do you belong?_______________________________

______________________________________________________________________________
Signature                                                                                                                                Date

Please make checks payable to Virginia Voters For Animal Welfare and mail to:

Virginia Voters for Animal Welfare
3318 Bust Head Road
The Plains, VA 20198