NATIONAL GRANGE MEMBERSHIP RECOGNITION APPLICATION

Form M

GOLDEN SHEAF, DIAMOND CERTIFICATE, SPECIAL LETTERS Rev. Jan 2013

This certifies that the members listed below are members of ______Grange, number ______in the County of ______State of______have beencontinuous members entitled to official recognition.

PLEASE TYPE OR PRINT CLEARLY CHECK OTHER SIDE OF THIS APPLICATION FOR THE APPLICABLE FEES.

Member’s Name§ / Address / Grange Name and Number / Month/Year / Month/Year / Recognition
Joined / Demitted / Requested*

§PRINT NAMES EXECTLY AS THEY ARE TO APPEAR ON THE CERTIFICATE*e.g. 50, 75 Year Certificates and Special Letters

I certify the foregoing is a correct statement of membership ______,Secretary (Subordinate)

Date:______

Mail Membership Recognition to: (please print or type)

______

______

Seal of Seal of State Grange ______

Subordinate Grange

Signed______,Secretary (State)

Date:______

INSTRUCTIONS

1.This application form is to be used for ordering Golden Sheaf Certificates, Diamond Certificates, and special letters from the National Grange Master to recognize 80-Year, 85-year, or other membership accomplishments.

2.To be eligible for these recognitions, a person must have been a member of the Grange continuously for the number of years indicated.The membership need not have been in only one Grange.

3.PRINT OR TYPE the name of the applicant EXACTLY as it is to appear on the certificate or letter.

4.If a member has belonged to more than one Grange, use the next line or lines to list name and number of all Granges and dates joined or demitted.

5.The Subordinate Grange Secretary completing the form should sign the application certifying that the information is correct and affix the Grange seal.

6.The application form, along with the proper payment, should be mailed to your State Grange for certification and seal.

7.The charge for the Golden Sheaf Certificate is $10.00 each; for the 75-Year Diamond Certificate or folder, $5.00 each; for special letters of membership recognition, there is no charge. Make checks payable to: The National Grange.

8.Golden Sheaf Certificates will not be issued more than 90 days ahead of the anniversary date without special approval of the National Master.

9.Please allow three weeks for delivery of the award.

10.Appropriate Golden Sheaf pins are available from your State Grange or the National Grange Sales Department, 1616 H Street, NW, Washington, DC20006. Toll-Free Telephone Number: 1-888-447-2643, ext 103.

Further Instructions - Revised by Ohio State Grange –January, 2013

1) This Gold Form is to be used ONLY for 50 and 75 year certificates and special letters from National Grange. There are no 50 and 75 year seals. Certificates come from the National Grange. To order 25 Year Silver Star Certificates, 40, 55, 60, 65, and 70 year seals, use the PINK“Ohio Grange Membership Recognition Application” form, dated January, 2013, available by contacting Ohio State Grange, 16303 Village Parkway, Fredericktown, OH 43019-9585, 740.694.1669, or The Ohio Grange Membership Recognition form is also online at under “Forms” then “Membership Recognition” then “Ohio State Grange“.

2) For items ordered on the reverse side of this gold sheet, there is no shipping and handling charge, and anything ordered from the National Grange is sales tax free. For items on this form only, make check PAYABLE to The National Grange and mail that check and this form to Ohio State Grange, 16303 Village Parkway, Fredericktown, OH 43019-9585.

3) Make sure the other side of this form is completely filled out including “Mail Membership Recognition to:” name and address. If you need more forms, contact Ohio State Grange, 16303 Village Parkway, Fredericktown, OH 43019-9585, 740.694.1669, or This form is also online at under “Forms” then “Membership Recognition” then “National Grange

MAKE SURE TO USE THIS LATEST FORM – January, 2013 – AND THROW ALLOTHER GOLD FORMS AWAY! !