TREE OF LIFE ORDER FORM

Please PRINT order form (this cannot be done through the website) and return with payment to:

Mrs. Dinah Taylor

804 Main Street

Williamsburg, KY 40769

I/We are Bereaved Parent(s) Name(s): ______________________________Other __________________

Mailing Address: ______________________________________________________________________

City: ___________________ State: _____ Zip: _________ Telephone: ()_____________________

Child(ren)'s Name(s): _______________________________________________ Age(s):_____________

Birth Date(s) ________________________________ Death Date(s)______________________________

Cause of Death(s) ________________________________Symbol(s)_____________________________

E-mail Address_________________________ Website________________________________________

All leaf payments must be received before the leaf can be engraved. Make all checks payable to University of the Cumberlands for J.I.M.'s Tree of Life. If you would like to pay with a credit card, please call the President's Office at 606-539-4202 and tell them you would like to order a leaf for J.I.M.'s Tree of Life. The leaves will allow for up to 24 print spaces on each line. Letters, commas, spaces, etc. are considered print spaces.

Leaf # 1

Line 1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Line 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Line 3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Leaf # 2

Line 1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Line 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Line 3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Enclosed is my check in the amount of $________ for ________(leaf(s) @ $50.00 each

___ I am donating a leaf(s) in honor or memory of another family and want you to notify them:

Name ________________________ Address_______________________________

City ________________________ State _____ Zip ___________

Enclosed is my check in the amount of $ _________ for _______ leaf(s) @ $50.00 each.