Ohio21 Club Sterling Silver Pin Order Form $300.00 ea.
A great way to support RWB Rich Dickerscheid as he approaches the Grand East! The Ohio21 lapel pin is a piece of fine jewelry made of Sterling Silver. They are individually numbered from 1-300, making each unique. Proceeds will be used to offset the costs not budgeted by the Grand Lodge of Ohio as well as special programs of the Grand Master during his term.
How many pins would you like to order? *
(Quantity)
What pay plan would you prefer? (per pin) *
(You will be contacted for delivery when your balance is paid-in-full.)
Full Name *
Your answer
Shipping Address *
(Include apartment, unit or suite number.)
Your answer
Shipping City *
Your answer
Shipping State *
Shipping ZIP Code *
Your answer
E-mail Address *
Your answer
Phone Number
Your answer
Your Lodge Name & No. *
Your answer
Bank Name *
(Name of your bank or credit union.)
Your answer
Name on Account *
(Lodge or Individual's name that appears on your checks.)
Your answer
Billing Address *
(Include apartment, unit or suite number.)
Your answer
Billing City *
Your answer
Billing State *
Billing ZIP Code *
Your answer
Bank Routing Number *
(First set of exactly 9 digits appearing at the bottom of your checks.)
Your answer
Account Number *
(Second set of numbers appearing at the bottom of your checks.)
Your answer
Example Check
Authorization to initiate a DEMAND DRAFT from your checking account.
By submitting this order form, I hereby authorize the Southwest Ohio Grand Lodge Fund to initiate a monthly DEMAND DRAFT from the checking account indicated above. I also authorize my depository financial institution to honor this draft. This authorization is valid for monthly transactions listed above until the balance is paid-in-full. I have read and agree to all of the terms and conditions on this page. I certify that I am the authorized account holder or representative for this checking account. I understand I will receive images of the demand drafts in my monthly statements when the items have cleared. I understand this is a legally binding agreement between me or my organization and the Southwest Ohio Grand Lodge Fund.
By clicking SUBMIT below, I certify that the above information is true and correct to the best of my knowledge, and that such submission constitutes a Digital Signature. [Conforming to the E-SIGN Act of 2000 - 15 U.S.C. Ch. 96]
Ohio21 Fundraising Committee
Questions? Contact:
RWB Larry A. Gillinger, Chairman
M: 513.319.6060
larry_gillinger@yahoo.com
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