Replacement Sign Form Historical Society Of Michigan Page 2
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4MICHIGAN CENTENNIAL FARM PROGRAM
Replacement Sign Form
The Historical Society of Michigan
Centennial Farm Program
5815 Executive Drive, Lansing MI 48911
Phone: (517) 324-1828
Fax: (517) 324-4370
Office Use Only
SECTION 1: ORDER
Which type of replacement sign would you like to order? Please indicate in the box if you would like to purchase more than one.
Centennial Replacement Sign - $91.50
If you selected Centennial Replacement Sign, in what year was the farm
certified as a Cenntennial Farm by the Centennial Farm Program?
YEAR
Sesquicentennial Replacement Sign - $46.10
(Rectangular sign to hang below Centennial sign)
If you selected Sesquicentennial Replacement Sign, in what year was the
farm certified as a Sesquicentennial Farm by the Centennial Farm Program?
YEAR
SECTION 2: BASIC FARM INFORMATION
Farm’s Founding Owner(s):
Farm’s Address:
County:
Township:
Has any part of the certified farm been sold since certification? Circle one: YES NO
Electric Company:
Number of acres currently owned:
SECTION 3: CURRENT FARM OWNER INFORMATION
Name(s)
E-mail
Phone
Did you own the farm at the time it was originally certified by the Centennial Farm Program? Circle one:
YES
NO
If yes, please move on to Section 4.
If no, what is your relation to the person who
was the owner at the time of certification?
If no, on what date did you purchase the farm?
SECTION 4: CONTACT AND SHIPPING INFORMATION
Marker will be shipped to the current farm owner at the farm’s address unless otherwise requested:
Relation to Applicant:
Contact Name:
Shipping Address:
Contact Phone:
Contact E-mail:
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