If you are interested in becoming a member of the Sampson Fund and/or wish to make a donation to the Fund and/or would like to volunteer your services to the Fund, please fill out, print, and mail the form.

First Name
Last Name
Street Address
City
State
Zip Code
Telephone Number
Email Address

Type of Membership (Check One)
Member (Annual Fee $25)
Sponsor ($50.00)
Patron ($100.00)
Group Member (Annual Fee $250)
Other

I Wish my donation to be made in memory of the following loved one ______________________________________

Donation-$

Total Enclosed-$

Signature____________________________________________

Would you like to be a Volunteer? (Check One)
Yes No

Please mail form along with any membership fee and/or donation to:
The Sampson Fund Veterinary Care
P.O. Box 1756, Orleans, MA 02653


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