Enchanted Lantern Request Form

each Lantern costs $50.00

To the Humanitarian Foundation@Supreme Council Grottoes of North America
(it may be easier to fill form out on computer, then print)

Date Total contribution enclosed for request:

PERSON BUYING:

PERSON BUYING (SELECT)

PERSON RECIEVING:

Return Lantern & Emblem to:
Grotto Name Title: (select)

Name Address

City, State, Zip

Enchanted Lantern Emblem Type: Choice of one per person

Tab Number: Bolo/Neck Tie Color:

Please issued Enchanted Lantern Certificate(s) in the name(s) listed below, left hand side. If purchased for someone else, please list that information on the right side of form. If the name pertains to a Prophet, indicate in box on left side. Also indicate type of lantern, post, pin, charm, tab number desired, bolo tie or neck tie and denote color. Earrings or Cuff Links require the purchase of two Enchanted Lanterns plus an additional $10.00. Bolo Tie and Neck Tie may be purchased with the one Enchanted Lantern plus an additional $10.00.
If no Certificate is required, please check box:

To make a Contribution to the Humanitarian Foundation,
type in complete information, print this form, and mail with your check or money order:

Humanitarian Foundation
1696 Brice Rd
Reynoldsburg, OH 43068


If Enchanted Lantern is to be mailed to a different address, please list:

Name of recipient: Address:

City, State, Zip:

FORM DOWNLOADED FROM WWW.ISLAMGROTTO.COM
WHEN DONE PRINTING, SIMPLY CLOSE THIS PAGE.