Request for Membership Numeral Pin (5, 10, 15 years)

Request for Membership Numeral Pin

(5, 10, 15 years)
The Membership Numeral Pin recognizes the total years of registered membership in Girl Scouts at five-year intervals. Years as a girl member plus years as an adult member are combined and counted toward this recognition. This request is for membership years totaling 5, 10, or 15-years.

*Membership Numeral Pin is provided by the local Service Unit.
Today's Date *

Month Day Year
Candidate's Information:
Name *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone
Service Unit *
Troop/Group #
Email *
Nominee's Current Position
Is nominee a currently registered member?

Yes No Unsure
Please check one: *

5-year pin 10-year pin 15-year pin
Requestor's Information:
Name *

First Name Last Name
Email *

Confirmation Email
Thank you for your nomination and all you do for Girl Scouting!
Should be Empty: