THIS FORM MUST BE TYPED
Annex A
Order Form for the Honorable and Ancient Orders of
Saint Barbara and the Order of Molly Pitcher

_____________
Date of Request

1. Identify below the Nominating Authority for the award.

___________________________________ Signature of Nominating Authority
___________________________________
Signature block of Nominating Authority
___________________________________

___________________________________

2. Identify below the Approving  Authority for the award.

___________________________________
Signature of Approving Authority
___________________________________
Signature block of Approving Authority
___________________________________

___________________________________

(Note: The Signature Block for the Certificate will be the same as the Approving Authority unless otherwise specified.)

3. Identify below the awardee and provide all requested information.

____________________________________
Type the Rank and Name EXACTLY as you want
it to appear on the Certificate.

____________________________________
Date of Award Ceremony to be Shown on the Certificate.

4. Award Desired: Ancient _______ Honorable _______ Molly Pitcher _______

5. Enclose $20.00 for each Honorable, Molly Pitcher and Ancient Award requested. Make all checks payable to the Air Defense Artillery Association. If requesting U.S. Postal Service Express Mail, enclose an additional $3.00. If requesting U.S. Postal Service Overnight Mail, enclose an additional $20.00.

6. Address to which the awards are to be sent OR the phone number to call so that the Awards may be picked up.
__________________________________ Honorable/Mollys requested ___x $20 = __________

_________________________________ Ancient Awards requested         ___x $20 = ________

_______________________________________ Additional Postage             _______________

                                                                                                                                      Total Enclosed ___________

Mail Requests to:
Air Defense Artillery Association, P O Box 6101, Fort Bliss, Texas 79906
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