You are on page 1of 1


Your donations will help secure the future of USOH to positively impact its clients. Please make
checks payable to: USOH, P.O. Box 8576, Missoula, MT 59807. All donations are tax deductible
to the fullest extent of the law. Please choose one of the following:

Membership: YES! I want to support USOH by becoming a Member!

Individual Annual Membership for $30.00

Family/Organization Annual Membership for $100.00

Join USOH! Your membership will help fund our annual programs. . Your membership is valid
for one year from the date membership dues are received.

Special Donation: Amount: $_________ Purpose:______________________

Monthly Pledge: $________ Start Date: ________ # of Payments: ____________

Name ______________________________________________________________________
Address _____________________________________________________________________
City/State/Zip _______________________________________________________________
Phone ____________________ Email ___________________________________________

Type of Payment: Check Visa Master Card

Card Number ___________________________ Expiration _________ Sec Code*______

Name on Card _____________________________________________
Signature _________________________________________________
( Sec Code is the last 3 digits of the numbers located in the signature box on the back of your credit card.)

For Monthly Pledges- Your signature authorizes USOH to submit monthly charges for the number of payments
specified or until your request us to discontinue your monthly pledge. You can also pay with an automatic payment
that you set up yourself with your bank.

Honorarium: I would like this donation to be (choose one):

In Memory In Honor Of: _______________________________________________

Send Acknowledgement to ______________________________________________________

Address _____________________________________________________________________

USOH P.O. Box 8576 Missoula, MT 59807 * 406.880.0696 * 406.370.5492 *