Chapter Name ____________________________________________ Chapter No. ______________

City/Town _______________________________________________  District No. _______________

Committee Chairman or Chapter President ________________________________________________

Address___________________________________________________________________________

Email __________________________________________  Phone ____________________________

Number of Southern Cross of Honor Medals located and/or reported to UDC _________

Number of Southern Cross of Honor Medals donated to the UDC  _________

Number of Southern Cross of Honor Medals donated to a Museum _________

Name of Museum ____________________________________________________________________

Address of Museum __________________________________________________________________

Date Donation was made _______________________________________________________________

Please mail completed form by August 15th to:
Vanessa Burzynski, Chairman
Southern Cross of Honor Committee
10933 Highway 90 North
Bedias, Texas 77831