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Order form for the honoarable and order of saint barbara and order of molly pitcher

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Revised 2/8/16

signature & Signature block below of the nOminating authority

(must be a honorable order of saint barbara recipeint)

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POC INFORMATION:
Signature: /

poc pRINTED nAME: Click here to enter text.

Signature block: /
UNIT: Click here to enter text.
SIGNATURE & SIGNATURE BLOCK BELOW OF THE APPROVING AUTHORITY

(MUST BE AN ANCIENT ORDER OF SAINT BARBARA RECIPEINT

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CONTACT PHONE: Click here to enter text.
(No DSN)
Signature: / CONTACT EMAIL: Click here to enter text.
Signature block: /
SHIPPING ADDRESS:
ALL ADDRESSES MUST BE CIVILIAN EXCEPT APO
(If recipient is different than POC please include name of recipient)
Click here to enter text.

PLEASE LIST ALL NOMINEES BELOW (for more than 4 nominees continue to next page)

All nominees MUST be ADAA members, and will need to provide membership # for verification purposes.

If membership needs to be obtained please do so before submitting nomination

*Foreign soldiers are the only exception to membership

NOMINEE NAME (As it will appear on certificate)
/ ADAA MEMBER#
(required) / DATE OF AWARD CEREMONY /
Award Desired
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐

Please figure total cost below

PRICES: Award: $30.00/each Postage: $5.00/each / Payment Options:
Pay by Debit/Credit Card (below) or send signed Money Order to:
ADAA
PO Box 33727
Ft. Sill, OK. 73503
**Multiple payments cannot be accepted, and will be returned to the sender, delaying the nomination process and potentially causing the nominations to be late.
Award type / QTY / Total for awards / Postage / Total
Subtotal / Click here to enter text.
CREDIT CARD PAYMENT
Card Holder Info:
Name: Click here to enter text.
Billing Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Email: Click here to enter text. /
Authorization Amount $ Click here to enter text.
Card type: MasterCard ☐ Visa ☐ AMEX ☐ Discover ☐
Card # Click here to enter text. Exp. Date: ____/____
CVV2 (3 digit # on back of Visa/Mc, 4 digits # on front of AMEX) Click here to enter text.
I authorize the ADAA to charge the credit card indicated in this authorization form according to the terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Card Holders Signature/Date: Click here to enter text.

PLEASE LIST ALL NOMINEES BELOW (continued)

All nominees MUST be ADAA members, and will need to provide membership # for verification purposes.

If membership needs to be obtained please do so before submitting nomination

*Foreign soldiers are the only exception to membership

NOMINEE NAME (As it will appear on certificate)
/ ADAA MEMBER#
(required) / DATE OF AWARD CEREMONY /
Award Desired
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐
Click here to enter text. / Click here to enter text. / Click here to enter text. / Honorable ☐ Molly Pitcher ☐