SAMF Wall of Honour Form
Fill out this Secure Online form below

or

You may Fax us at
902-461-1610, OR
Phone toll-free to 1-888 497-7779
Local: 461-0062

Email: Province / State: Name: Postal / Zip Code: Address: Phone Number: City: Fax Number:         Tile Option: Option A $300 Option B $600 Option C or D $600 Please select option:

I am paying by:	ChequeCredit Card
Card Number:
Expiry Date:	Month010203040506070809101112   Year17181920212223242526
3 Digit Security Number on Back of Card:

ENGRAVING REQUEST The colour of the tile will be ‘Belmont Rose’. If the submission requires any alteration, the subscriber will be contacted by phone or email by the coordinator for further discussion. REMEMBER TO COUNT THE SPACES!
Tile Description: Describe your engraving details in the space below. Count the lettering for each line as described in our cover page. Please check accuracy before sending - we are not responsible for any misspelled words. We will contact you on receipt and review of your order.

Please check engraving details for accuracy before sending. We cannot be responsible for misspelled words on your order form.

For further information, please call the SAMF Secretary: Toll Free: 1-888-497-7779 or (902) 461-0062 | Fax (902) 461-1610
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