Membership Application Name:* First Last Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:*Email:* Membership Type*Business / Organization Membership ($50.00)Family Membership ($40.00)Single (Ages 18+) Membership ($20.00)Senior (Ages 55+) Membership ($10.00)Membership Status:*NewRenewingDo you wish be a Voting or Non-Voting Member?*VotingNon-Voting*Voting Members vote on Board of Directors, and changes to FDHS's Constitution and By-Laws.Please list representative authorized to vote:**Voting Members vote on Board of Directors, and changes to FDHS's Constitution and By-Laws.Would you like to Volunteer for FDHS*YesNoVolunteering Opportunities: (Check all that apply)* Foster Care Grooming Transporting Animals Animal Training Maintenance Cleaning Grant Writing Fundraiser Events Information Technologies Why are you interested in becoming a member of the Fort Defiance Humane Society?*The Fort Defiance Humane Society is a 501(c)(3) non-profit organization that encourages membership within its organization. The Society is not a county agency or department that is operated under the purview of the Board of Commissioners. The Society holds the right to deny or revoke membership to the following: Individuals or organizations that receive a fiduciary benefit from another Humane Society, animal shelter or animal rescue Individuals that have been convicted of a felony Individuals that have been convicted of any type of animal negligence Individuals with charges pending related to any type of animal negligence Individuals or organizations that do not promote the purposes of the Society Do you wish your Membership to be anonymous?* Yes No • All Memberships are effective until October 31. • By clicking "SUBMIT," you agree that you are age 18+ at the date of this application, and that all information is correct. • FDHS respects your privacy and will not share your personal information.Total $0.00 NameThis field is for validation purposes and should be left unchanged.