I (we) wish to make a donation to the American Cavalier King Charles Spaniel Club Charitable Trust:

Amount $__________________________________________ (any amount is appreciated)

Person(s)/Organization making contribution: _____________________________________

_________________________________________________________________________

_________________________________________________________________________

Address: _________________________________________________________________

Phone: _______________________________ Email: _____________________________

In honor of: _______________________________________________________________

In memory of: _____________________________________________________________

Name and address of person to whom acknowledgement of honor or memorial is to be sent:

_________________________________________________________________________

_________________________________________________________________________

PLEASE USE MY CREDIT CARD FOR MY TAX DEDUCTIBLE DONATION:

Circle One: MASTERCARD VISA Card # ____________________________ Exp.________

Full name on card __________________________________________________________

Donation Amount $ _________________________________________________________

Signature: ________________________________________________________________

Checks are to be made payable to the: ACKCSC Charitable Trust, Inc.