Fax: (301) 599-1852  Phone: (301) 599-PETS
(Fax and phone for credit card orders only)
Postal mail:  IMOM, Inc. ~ PO Box 282 ~ Cheltenham, MD 20623

Name _____________________________________________

Address ___________________________________________

City, State and Zip ____________________________________

Your email address ___________________________________________

Amount of Donation ___________________________________

Do you want the whole amount to be used toward Blind dogs Y__ or N___

If Not: How much towards Blind dogs _____ Towards the general IMOM _____

I would like to use my Visa __ MasterCard __ American Express ___

My card number is:________________________________ Exp. date:_______

Your signature: ___________________________________________________

Please make checks payable to IMOM Inc.