Ofc. Ashworth Memorial Coin Fundraiser Order Form
Officer Ashworth is being memorialized at the National Officer Down Memorial  in Washington, D.C. on May 15, 2023. His name will be honored and placed on the wall of heroes that have given the ultimate sacrifice. Donations are requested to assist immediate family members and a few of his co-workers attend this sacred ceremony. Please consider donating to Officer Adam Ashworth's surviving family as a tribute to him and the service he provided. 

Two memorial coins have been created and orders are being taken now. To place an order, please fill out the following form.

Coins will be $15 each. Pickup is available at the St. George Police Department (we'll let you know when they arrive). Orders from officers within Washington County will be grouped and delivered in bulk to your agency. Shipping is also available for a set fee. 
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Phone Number *
Agency (If Applicable)
Orders from the same agency will be grouped together. 
Badge Coin
Quantity Ordered - Badge Coin - $15 each *
Valhalla Coin
Quantity Ordered - Valhalla Coin - $15 each *
Pickup/Shipping *
Shipping Address (If Applicable)
MUST include full address, City, State, ZIP to be shipped. 
Total Amount Due *
Please calculate your amount due for each coin ordered along with your preferred shipping charges. 
Payments can be made via Venmo to the Dixie Lodge 35, our local Fraternal Order of Police at https://account.venmo.com/u/DixieLodge35 
Clicking this link will open a new window for you to pay via venmo. Once you complete that process, return to this window and complete this form. Any additional funds donated will be applied to this same fundraiser. 
https://account.venmo.com/u/DixieLodge35
Checks can also be made out to the St. George Police Department. Please include your name/# coins ordered with the check. 

Mail checks to: 

St. George Police Department
Ofc Ashworth Memorial Coin Order
265 North 200 East
St. George, UT 84770
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of City of St. George. Report Abuse
Google Forms