For ACS use only: Total Funds Collected: ____________ Verified by: _____________________ Signature: ______________________
Name: _______________________________________________Team Name (if applicable): ________________________________ Address: _____________________________________________ City, State, Zip: __________________________________________ Phone: _______________________________________________Email: _________________________________________________ Name
Address
City, State, Zip
Phone
Pledge Amount
1. 2. 3. 4. 5. 6. 7. 8. * Checks should be made payable to the “Animal Care Sanctuary”
Page1 Subtotal: ________________ Page2 Subtotal: ________________ Online Subtotal: ________________ Grand Total: ___________________