Please supply information below by typing or printing.

RECIPIENT OF AWARD:________________________________________________________
(Name of individual, particular church, presbytery, or synod as it should appear on the certificate)

DESCRIPTION AND DATE OF EVENT, ANNIVERSARY, OCCASION:____________

_____________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

DATE AWARD NEEDED:_______________________________________________________

MAIL AWARD TO:___________________________________________________________

______________________________________________________________

______________________________________________________________
(Name and address)

APPLICATION MADE BY:__________________________________________________________

_____________________________________________________________

______________________________________________________________
(Name, address, and telephone number)