1778 Society - Order Form

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Join the 1778 Society to receive a medallion and support the 250th Anniversary of the Grand Lodge, A.F. & A.M., of Virginia

Email *

Your Title (Bro. WM, RW, MW, etc.) *

Brother (Bro.)

Worshipful (Wor.)

Right Worshipful (RW/Rt. Wor.)

Most Worshipful (MW/Mt. Wor.)

Other:

Your Name (First, Middle, Last) and Suffix (II, jr, etc.) *

Donation Level *

Bronze ($250)

Silver ($500)

Gold ($1,000)

Platinum ($2,500)

Payment Method *

Cash

Check

Credit Card (One time payment)

Pay over 10 months (Gold Level = $100/mon. | Platinum Level is $250/mon.) Medallion will be provided upon full payment.

Enter Check Number

Perferred method for receiving medallion *

Presented in Lodge (i.e. at Stated Communication) for GOLD and PLATINUM Level only.

Shipped to my residence

Pick up at event (DELC, GAC, etc.)

Lodge Name & No. *

Masonic District No.

Lodge Physical Address (street, city, state, zip code)

Your email address

Your preferred phone number *

Your USPS mailing address (street, city, state, & zip) *

Notes/Additional Information (anything else you want us to know about your purchase): *

Thank you for your order and supporting the GLoVA's 250th anniversary. Please rate your ordering experience.

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A copy of your responses will be emailed to the address you provided.

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