Please fax or mail this form.  *Equals Required Field

Buyer Name:* ____________________________________

Organization/School
(if applicable): ____________________________________

Street Address:* ____________________________________

City:* ____________________________________

State:* ____________________________________

Zip Code:* ____________________________________

Daytime Phone: (______)______-_______________________

Evening Phone: (______)______-_______________________

Email:* ____________________________________

Animal to be Adopted
Animal Selected: ____________________________________


Gift Information
Make it a gift  [ Yes / No ] (Circle one)
Mail package to: [ You / Recipient ] (Circle one)

Recipient Name:* ____________________________________
                         (This name will be printed on the certificate)

Street Address:* ____________________________________

City:* ____________________________________

State:* ____________________________________

Zip Code:* ____________________________________

Daytime Phone: (______)______-__________

Evening Phone: (______)______-__________


Giving Level
__ Individual Adoption $40
__ Special Adoption $50 (plush available while supplies last)
__ Club Adoption $100
__ Group Adoption $500
__ Zoo Keeper $1000
__ Additional plush animal (special adoption only) +$10

Total Enclosed: ____________

Payment Information Note: This is not an SSL secure form.

Payment Type (circle one):   VISA   MASTERCARD   AMERICAN EXPRESS   DISCOVER

Name on card: ____________________________________

Card Number: ____________________________________

Expiration Date: _____/_________ 

CVV Code: ____________
CVV is the three digit verification number on the back (or four digit on the front of your American Express) of your card.

Please fax this form to (248) 541-0344 or mail to:

Detroit Zoological Society
WildLife Preservers - "Adopt" an Animal
8450 W. 10 Mile Road
Royal Oak, MI 48067