(please print form)

Circle of Life Fund Application

Yes, I want to make a monthly pledge so that my gift can be put to work quickly and effectively to help HCHS care for the homeless animals of Horry County! I authorize a monthly payment of:

___ $20      (less than $1.00/day!)

___ $50      (less than $2.00/day!)

___ $100   (less than $4.00/day!)

I choose to make my monthly payment by:

___ DIRECT CHOICE: Credit Card

I want to make my monthly contribution with my credit card. I understand that the amount I choose will automatically be charged to my account each month.

___VISA   ___ Mastercard   ___ AMEX   ___ Discover

Credit Card #: _________________________________

Expiration Date: ________________

Signature: _____________________________________

OR

___ DIRECT CHOICE: Automatic Bank Payment

I want to use electronic fund transfer to make my monthly contribution. I am enclosing s check for my first month’s donation, and a voided check from the account that I wish to use. I authorize a monthly transfer.

Please print the following information:

Name: _______________________________________

Address: ____________________________________

City: ________________ State: _____ Zip: ________

Phone #: ____________________________________

Please mail form to:  

 HCHS, 2101 Industrial Park Rd.,  Conway, S.C. 29528