| First
Name |
Middle Name |
Last Name |
|
|
|
|
| Rank |
CSA |
|
|
USA |
|
|
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 $50 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 |
Credit Card # |
Expiration |
Check
MasterCard
Discover
American Express
Visa
Diners Club |
|
/
|
| Name
of presenter: |
|
|
| Name
of recipient: |
|
|
| Occasion: |
| Address |
|
|
|
Mail
certificate to: |
|
|
Presenter
Recipient |
|
|
