* = Required Input

Date*:

Title (Mr., Mrs.,etc.)*:

Name*:

Co-Donor Title (if joint):

Co-Donor Name (if joint):

Address*:

City*:

State or Province*:

Country*:

Postal Code*:

Telephone Number*:

Cell Phone Number:

Email*:

Local Camellia Club/Society:

It is the practice of the American Camellia Society to recognize contributions in a printed listing in The Camellia Journal. Please indicate below how you would like to be recognized.

Recognize my/our gift

I/we prefer that my/our contribution remain anonymous and not be included in any published acknowledgement list.

I/we would like my/our contribution to be listed In Honor of - see below.

I/we would like my/our contribution to be listed In Memory of - see below.

Title (Mr., Mrs.,etc.):

Name(s):

City:

State:

Club Affiliation (if applicable):

Note:

It is the practice of the American Camellia Society to send a letter to either the person being recognized or his or her family/friend, if the person is deceased.

Send a letter to the person being recognized.

Send a letter to the family or a friend of the person being honored.

Title (Mr., Mrs.,etc.):

Name(s):

Address:

City:

State or Province:

Country:

Postal Code: