PLEASE TYPE YOUR ANSWERS IN, THEN PRINT AND SIGN.

As a non-profit 501(c)(3) rescue organization, your E.P.O.N.A. sponsorship if fully tax-deductible.

YOUR FULL NAME: 

YOUR STREET ADDRESS AND/OR PO BOX: 

YOUR CITY, STATE, AND ZIP CODE: 

YOUR HOME TELEPHONE NUMBER: 

YOUR HOME E-MAIL ADDRESS: 

YOUR WORK TELEPHONE NUMBER: 

YOUR WORK E-MAIL ADDRESS: 

YOUR FAX NUMBER: 

RETIREE(S) YOU WISH TO SPONSOR: 

PLEASE PUT AN X IN ONE OF THE FOLLOWING BOXES:

FULL SPONSORSHIP ($250.00):         PARTIAL SPONSORSHIP:   IF PARTIAL, PLEASE TYPE IN AMOUNT: $.00

__________________________________________________                    ___________________________________

YOUR SIGNATURE                                                                                  TODAY'S DATE

Please print this form, then sign and date it.

When complete, please send along with your check or money order to:

E.P.O.N.A., PO Box 315, Epping, NH  03042-0315

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E.P.O.N.A.     PO Box 315      Epping, NH  03042-0315     603-679-1896

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This page was last updated on 01/29/2003.