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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:

____________________________________


STATUE DONATION LEVELS

 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)
$15.00
$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

Make check or money order
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".




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