Online Payment Form

For payment of adoption fee, auctions, raffle tickets, and other purchases.

For donations, please visit this page instead.

Name*
(Please use legal name.)
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Click ONE BUTTON to designate what this payment is made to cover*
- Adoption fee (For those who have already been approved through ESRA's adoption application process)
- RAFFLE TICKET
- Winning bid at AUCTION
- ESRA Illinois/N. Indiana 2023 picnic admission or raffle
- Other reason (Please specify)
Raffle Tickets
Note: Once your payment is confirmed, you will NOT receive actual tickets but you WILL receive an email copy of this form, documenting the number(s) of the ticket(s) assigned to your name.
Quilt Raffle Tickets Quantity
Price: $10.00
Lladro Surfer Boy Raffle Tickets Quantity
Price: $10.00
Auction Items
What item did you win?*
What is the Fair Market Value (FMV)?*
Amount of Auction Item Payment*
Note: Any amount of the winning bid that exceeds the fair market value of the prize may be tax-deductible.
Other*
Please specify.
Congratulations!
Dog's Name:*
Dog's Intake Number:*
Amount of Adoption Fee*
We ask you to consider making an additional donation to ESRA for veterinary expenses that weren't included in the adoption fee that you are about to pay. The average cost of care for each dog that we take into ESRA approaches $1000, and we recover a little over a third of that through our adoption fees.

All donations are tax deductible and you will receive a receipt from us for tax purposes.
Additional Donation*
Amount of Payment (for other reason)*
Auto Total
$0.00
Comments? (Please add here any information needed to clarify the intent of your payment.)
After submission of this form, your window will be passed to Paypal to securely process payment. You do not need an account to utilize this.
Paypal name and email (if different than above)
If you do use a personal Paypal account with a different name and email that you submitted above on this form, please let us know below so we can match your payment with your form.
Comments
This field is for validation purposes and should be left unchanged.

Beautiful black and white tricolor smiling Springer

Online Payment Form

For payment of adoption fee, auctions, raffle tickets, and other purchases.

Raffle Tickets

Auction Items

Congratulations!