Please print, fill out and submit with your payment.

Pet Name:   

   

Pet Date of Birth:   

   

Pet Date of Death:   

   

Owners Name:   

   

Address:   

   

   

Share your Memories:   

Please turn paper over should you need additional space.

    
   
   
   
   
     

Type of Memorial:   

 
 
 

   

I have enclosed my cheque or money order payable to the Brant County SPCA

or

Please charge my Visa          or MasterCard          

    Card Number:                                                                              
    Expiry Date:            /           
    Signature:                                                                                    
     
    Total Amount Enclosed:                                    
     
   

     

                                                                             

If you send a photo and wish to have it returned, please enclose a self-addressed stamped envelope.

Brant County SPCA cannot be held responsible for any lost photos.