Form Rt: Kmh - Request For Membership Numeral Guard Pins And/or Years Of Service Pins Form Page 2

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Request for Membership Numeral Guard Pins and/or
Years of Service Pins - 15 Years or More
Years of Membership Numeral Guard pins (girl and adult membership combined) and Years of Service Pins (as an adult
volunteer) are available only in increments of five years (5, 10, 15, etc.) Years of Membership recognition is a numeral
guard to be worn with the Girl Scout Membership Pin. Volunteer Years of Service recognition is a separate numeral pin
with the appropriate number years on the pin.
15 years or more of service or membership can be presented at the Volunteer Conference and Celebration (VCC) or
awarded at an appropriate service unit event. Note: Please indicate your choice. These awards are provided by the
council.
For pins distributed at the Volunteer Conference and Celebration, a completed form must be received at Balboa
Service Center no later than 4:30 p.m. on May 15
th
. Fax to 619-298-2031 or mail/drop-off 1231 Upas Street, San
Diego, CA 92103.
Recognitions are requested for the following currently registered adults:
Membership:
Service:
Name: __________________________________________________
(circle # of years)
(circle # of years)
Address: _________________________________________________
15
20
15
20
________________________________________________________
25
30
25
30
Telephone: (____________) _________________________________
35
40
35
40
45
50
45
50
E-mail: __________________________________________________
55
Over 55:___
55
Over 55:___
(circle one) Receive at VCC / Pick up for SU event
Membership:
Service:
Name: __________________________________________________
(circle # of years)
(circle # of years)
Address: _________________________________________________
15
20
15
20
________________________________________________________
25
30
25
30
Telephone: (____________) _________________________________
35
40
35
40
45
50
45
50
E-mail: __________________________________________________
55
Over 55:___
55
Over 55:___
(circle one) Receive at VCC / Pick up for SU event
Membership:
Service:
Name: __________________________________________________
(circle # of years)
(circle # of years)
Address: _________________________________________________
15
20
15
20
________________________________________________________
25
30
25
30
Telephone: (____________) _________________________________
35
40
35
40
45
50
45
50
E-mail: __________________________________________________
55
Over 55:___
55
Over 55:___
(circle one) Receive at VCC / Pick up for SU event
Requested by:
Name: ______________________________________ Service Unit: ________________________________________________________
Address: ________________________________________________________________________________________________________
Telephone :(__________) ______________ Email: ____________________________________________________________________
Recognitions Chair Approval Signature: __________________________________________________
Date: ______________
Council Approval Signature: ____________________________________________________________
Date: ______________
RT: KMH
RE-0011 11-16-12

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