Check here for Park staff to research the rank, if unknown.
Company,
Unit, State, and Branch of Service (i.e.. 12th
Virginia Infantry):
Check here for Park staff to research Company, if unknown.
In
order for Park staff to perform research on a
soldier, please provide as much information as
possible, including age, hometown in 1860, and
branch of service with unit designation, if known.
Remembered
By:
PURCHASER
INFORMATION
Mr.
Mrs.
Ms.
Name
Address
City
State
Zip
Phone
E-mail
address (optional):
(
)
-
Checks
in the amount of $75 should be made payable to
Pamplin Historical Park. Those ordering by credit
card may fax this form to (804) 861-2820.
A
Presentation Certificate will be mailed to acknowledge
the order. If the order is a gift, please fill
out the information below.
Method
of Payment: $75
Credit Card #
Expiration (MM/YY)
Check
MasterCard
Discover
American Express
Visa
/
Credit Card Billing Zip
Security Code CVV/CSC: (Visa, MC, Disc: 3-digits on back of card; AMEX: 4-digits on front of card)
Name
of presenter:
Name
of recipient:
Occasion:
Address
Mail
certificate to:
City
State
Zip
Presenter
Recipient
Signature:
Date:
Print this form, and FAX or mail it to
us at:
Pamplin Historical Park
Attn: Administration
6125 Boydton Plank Road
Petersburg, VA 23803
