Please Note: All the following information is final as written !!
Print Clearly, and feel free to use additional pages if needed. 
 

Application for the Order of Silver Rose Award
Please Note: All the following information is final as written!!!
Print Clearly, and feel free to use additional pages if needed.
This application must be Totally Completed and mailed with
all requested information for consideration included!

Name; ___________________________________________________________
(Print the first, middle name or initial and last as you want it written on the award and
The Rank (I.E. Specialist E-4 etc. ) as you want it on the award.)
Address___________________________________________________________
City, State and Zip Code: _____________________________________________
Email Address, _____________________________________________________
Evening Phone number ; ( ) ________________________________________
Day number if available; ( )________________________________________
Branch of Service; _________________________________________________
If the person is deceased please list your name, relationship to applicant and your full address and phone number.
Your Name;________________________________________________________
Relationship;_______________________________________________________
Address;__________________________________________________________
City & State with Zip Code____________________________________________
Area Code & Phone Number __________________________________________

Just like everything else in this world...it all takes money
The producing of the Silver Rose Awards themselves,
The packaging and mailing, the communications,
The tax reporting and dozens of other things…
All require that someone “Pay’s the Bills”
That’s where You come in, If you believe that Honoring the
Victims of Agent Orange is a worthwhile endeavor,
Help Support the Cause.  Make a Donation!
Anything will help us sustain this Mission.
Without your help, We cannot continue!!
Please forward any Donations Payable to The Order of The Silver Rose

You must enclose copies of form DD214 and Medical Records showing Agent Orange related sickness or cancer and this application. This information is critical in preparing this award. The award will Not Be Prepared without it, Nor Will You Be Contacted if a Application is sent In Lacking the Required Information

Mail To!
Gary J. Chenett
National Director
9157 Ann Maria
                                    Grand Blanc, Michigan 48439
http://silverrose.info