To order, please print this form, fill out and mail:

Name________________________________________________________________

Address______________________________________________________________

Phone________________________________________________________________

I. Please circle your choice of The Official Memorial Pin®:
Sterling Silver      or     Silver Base Metal

II. If you choose to have us engrave your Pin, ($5.00 extra) please select from the following

    1. In the following entry, please print what letters you wish engraved on your Memorial Pin (limit is 7 letters):

     ___ ___ ___ ___ ___ ___ ___

2. Please circle the style of engraving you desire on your Pin:
JCP (bold)                 or                       JCP (script)

3.Please circle the sizes of the initials to be engraved: (eg., John Paul Crane)

JCP (Surname initial in center and larger)
JPC (All letters the same size)
John (First letter capitalized)

* Please list your charity of choice:

________________________________________________________

________________________________________________________

Please Make Checks Payable To:                        

       memorialpin, Inc.

       P.O. Box 415

       GENEVA, OH 44041 U.S.A.