Date ___________
District
______
Chapter Name & Number
_______________________________________________________
Name____________________________________ Phone (____) _________ Email Address ______________
Address:__________________________________________________________________________________
City: ___________________________________State:_____________ Nine Digit Zip Code:_____________
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1) Florida Division Official Pin, $15 + $1.50 postage ______ x $16.50 =________
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2) Chapter Top Bar, $10 + $1.50 postage ______ x $11.50 =_______
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3) Division Top Bar, $10 + $1.50
postage ______ x $11.50
=_______
(Note: To be worn by Florida Division Officers and Past Officers only)
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4) Chapter Officer Bar, $15 (includes engraving) + $1.50 postage______ x $16.50 = ______
Choose from the following:
Number Office Years Number Office Years
Vice President Historian
2nd Vice Pres Recorder
3rd Vice Pres Chaplain
Rec. Secretary Corr. Secretary
Treasurer Parliamentarian
Registrar
5) Division Officer Bar, $15 (includes engraving) + $1.50 postage ________ x $16.50 = ________
Choose from the following:
Number Office Years Number Office Years
Vice President Dir. District I
2nd Vice Pres Dir. District II
3rd Vice Pres Dir. District III
Rec. Secretary Dir. District IV
Treasurer Dir. District V
Registrar Dir. District VI
Historian Dir. District VII
Recorder Corr. Secretary
Chaplain Parliamentarian
6) Florida Division Page Pin, $25 + $1.50 postage (application needs to be completed) x $26.50 =
Make checks payable to: FL Div Treasurer, UDC Total $________
9677 Heather Circle West
Palm Beach Gardens, Fl 33410-5467
Ph: 561-622-4440