IOWA GENEALOGICAL SOCIETY ANCESTOR MEMORIAL WALL
Donor’s Name:_________________________________________________________________
Donor’s Address: _______________________________________________________________ _______________________________________________________________
Daytime Phone: ____________________________ Email: ____________________________
Credit Card Information: Visa MasterCard Discover
Name on Credit Card:______________________________________________________________ CVV _____
Credit Card Number: ___________________________________________ Expiration Date: _______________
NAME OF PERSON(S) EXACTLY AS THEY ARE TO APPEAR ON THE WALL:
(You have 40 spaces, including spaces between words. Please print VERY clearly.)
Name #1: $175.00 total
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Name #2: $350.00 total
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Name #3: $525.00 total
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Name #4: $700.00 total
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If you need space for additional names, please feel free to photocopy this form. At a later date, we will contact you regarding a media program that will be compiled with biographical sketches of those whose name appears on the Memorial Wall. It will be kept in the IGS library for the reference of future genealogists. Participation is optional, however, but we encourage you to share your stories at that time.
RETURN THIS FORM TO:
IGS WALL
628 E Grand Ave
Des Moines, IA 50309
