QFHS - Monument Inscription order form

Québec Family History Society Monument Inscription Mail Order Form

This form can be completed on-screen and printed on your printer.
Or you may print it and then fill it out, using CAPITAL letters.

Payment can be made by Visa (or by cheque / money order). For $US cheque / money order, send price of publication only, the exchange rate will cover the cost of postage and handling.

Date (mm/dd/yy):		Membership #:
Full Name:
Address:
City:		Prov / State:
Country:		Postal / Zip Code:
Email:

Cemetery name:
Town / Township:		County / Prov:
Religous Denomination:

Payment method:	Cheque Money Order Visa Total order:
For cheque or money order: $ Can $ US
For Visa:
Exact name on card:
Card number:		Expiration Date: /