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 =________

                            2) Chapter Top Bar, $10 + $1.50 postage                              ______ x $11.50 =_______

                                  
                            3) Division Top Bar, $10 + $1.50 postage                               ______ x $11.50 =_______
                            (Note: To be worn by Florida Division Officers and Past Officers only)

                                             
                          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                

              2^nd Vice Pres                                                         Recorder                

              3^rd 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           

              2^nd Vice Pres                                                         Dir. District II          

              3^rd 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    $________