Year award was received: ___________________

Name of Organization: _____________________

Name of Person: __________________________

Name of Entry: ___________________________

Category: _______________________________
___First Place (plaque $100)
___Second Place (certificate $20)
___Third Place (certificate $20)

Payment must accompany order. Checks payable to:
National Headliner Awards
226 Mt. Vernon Ave.
Northfield, NJ 08225

Mail plaque or certificate to:

Name _____________________

Address____________________

City________________State ______ Zip Code: ________

Person completing form: __________________________
Phone: ________________________

Please allow 4 - 6 weeks for delivery.