Commemorative Tile

Honor or memorialize a cherished pet or loved one. Your engraved message on tile will be a permanent fixture on the wall in the reception or hallway area of the Shelter.

Purchaser name:_______________________________________________

Address:_____________________________________________________

City: _________________________State ___________ Zip _____________

Email __________________________________Phone_________________

Preferred method of contact:    __ Mail        __ Email       __ Phone

Choose one:  _____$100 tile (6″ x 6″)         ______ $300 tile (12″ x 12″)

In the space below, please print your desired text clearly.

PAYMENT INFORMATION

Enclosed is my check payable to SCAS    

Please charge my contribution to   Visa      Mastercard

 _______________________________________________________

Account number                               expiration date

 Name on card (please print) _________________________________

 Signature ______________________________________________

 Mail this form to:   Surface Creek Animal Shelter (SCAS)

                               PO Box 853

                               Cedaredge, Colorado 81413

 For more information call 970-640-4907 or email    surfacecreekanimalshelter@gmail.com