Bereavement Certificate Form

Instructions:

Please fill out the following sections completely. We will custom print each certificate using the information you provide. The donor section should contain information about you. In the recipient section, please provide information about the individual you wish to give this certificate. Should you have questions regarding formatting or information placement, please see the Bereavement Certificates image or e-mail Heather Bowden.

Bereavement Certificates can be issued in any amount (over $5).

To add a listing to the Paw Prints On Our Hearts page, select the option below and enter the name and dates as you'd like them to appear. You may also add a short dedication. If you would like for your Paw Print to link to a picture, a longer story or an external URL, please contact Heather Bowden for more information. Your listing will stay on the page for one year. You may list any pet on the Paw Prints On Our Hearts page and if you prefer to list your pet without getting a certificate, please let us know in the comments section.

Information about the Donor:

Contact Name:
Street Address:
City:
State:
Postal/Zip Code:
Country:
E-mail:

Payment Method?
I will send a Check to the address provided below;
I will send a Money Order to the address provided below;
I will provide my Visa/MasterCard information by calling the phone number provided below;
I will use PayPal via the link provided below.

Bereavement Certificate Recipient:

Name (to Appear on Certificate):
Street Address:
City:
State:
Postal/Zip Code:
Amount:
E-mail:
Donation in Memory of:

Donation Made in Name of a Pet or Individual?
pet
individual

Comments?

The information provided in the Bereavement Certificate Section will be used to create and send a custom printed certificate to the above named individual(s). A formal donation etter will be sent to you utilizing the contact information you provided in the Donator Section. This donation letter will include the donation date, amount donated, and our Federal Tax Number. Please remember that all donations are tax-deductible and are very much appreciated. If you would like to include a personalized phrase, please feel free to do so in the Comments box in the section above.

I would like to include the following on the
Paw Prints On Our Hearts Page
Name:
Date of Birth:
Date of Loss:
Dedication:

To complete your request:

Please fill out this form completely, including your e-mail address. The requested information will allow us to contact you in the event of questions concerning your certificate order.

Visa Logo MasterCard Logo When your check or money order arrives we will ship your certificate. To pay by credit card, fill out and submit the order form to process your request. Then call 972-208-2470 between the hours of 8AM - 8PM CST to supply your credit card information.

Should you prefer to make your donation using PayPal, we have provided a link for your convenience.

If you wish to pay by check or money order, when your form is complete, please submit it (you may wish to print a copy for your records) and mail a copy, along with your check or money order, payable to LABMED, to:

LABMED, Inc.
3941 Legacy Drive, Suite 204, #A115
Plano, TX 75023

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