Annual Candle Form

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Name Name First Last
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
How many candles would you like to have lit?
Candle Inscription
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Second Candle Inscription
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Third Candle Inscription
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Fourth Candle Inscription
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Fifth Candle Inscription
Maximum of 150 characters allowed. Currently Entered: 0 characters.
How would you like to give your donation?

How would you like to give your donation? Cash/Check (Please make checks out to the National Shrine Grotto) Credit Card
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Would you like to receive email updates from the National Shrine Grotto?

Would you like to receive email updates from the National Shrine Grotto? Yes No I already receive emails from the National Shrine Grotto
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