Name:
Addr1:
Addr2:
City: State:
County: Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Fax:
Email:
Website:
Donation Amount:
Cash: Check #:
Date:
Donor's Signature:
____________________________________
Received By:
____________________________________
Addr1:
Addr2:
City: State:
County: Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Fax:
Email:
Website:
Donation Amount:
Cash: Check #:
Date:
Donor's Signature:
____________________________________
Received By:
____________________________________
Donation Level 1
Donation Level 2
Donation Level 3
Donation Level 4
Donation Level 5
Donation Level 6
Donation Level 7
Donation Level 8
Donation Level 9 (> $1000)
Donation Level 2
Donation Level 3
Donation Level 4
Donation Level 5
Donation Level 6
Donation Level 7
Donation Level 8
Donation Level 9 (> $1000)
$15.00
$50.00
$60.00
$75.00
$100.00
$150.00
$500.00
$1000.00
>$1000.00
$50.00
$60.00
$75.00
$100.00
$150.00
$500.00
$1000.00
>$1000.00
(For Donation Level 9, Manually enter the dollar amount in the Donation Amount field in the left column of this form)
International Donations can be made
for an additional $10.00.
International Donor
payable to:
Royal Order of Don Juan Ponce de Leon Historical Committee
Mail completed application
and money to:
U.T.B. United Third Bridge, Inc.
Royal Order of Don Juan Ponce de Leon Historical V Centennial Committee
P.O. Box 360505
Melbourne, FL 32936-0505
For questions regarding donations please call 321-863-5165, or send us your question at "utbroyalorder@gmail.com".