NAME _________________________________________________________________

ADDRESS______________________________________________________________

_______________________________________________________________________

PHONE NO. DAY______________________EVENING__________________________

MOBILE NO.____________________________FAX. NO.________________________

EMAIL ADDRESS________________________________________________________

ADULT: $11.50

CHILDREN: $5.25

FAMILY: $22.50

PLEASE COMPLETE:

Subscription___________________

Donation___________________

TOTAL ENCLOSED $ ___________________

Send to:
Wainuiomata SPCA
P O Box 43215
Wainuiomata