Free 49572.pdf - Indiana

HOOSIER HOMESTEAD CERTIFICATE, SIGN AND PHOTOGRAPH ORDER
State Form 49572 (R5 /11-04) Form approved by State Board of Accounts, 2004

Please review the following information. It will be used to personalize your certificate. If any information is incorrect, please call us at 317/232-8770. County: Award Name: You will receive on certificate at no charge. If you wish to purchase additional items, please choose from the list below: Item Hoosier Homestead Aluminum Yard Sign @ $31.00/each (Printed on Both Sides) - Sign will be appropriate to award Postage for shipping UPS @ $10.00* (up to six signs) (If requesting more than 6 signs, call for new rate) Hoosier Homestead Centennial Certificate @ $7.00/each Hoosier Homestead Sesquicentennial Certificate @ $7.00/each Hoosier Homestead Bicentennial Certificate @ $7.00/each 8" x 10" Color Photograph @ $9.00/each $ $ $ $ $ $ Amount Farm Origin Date:

Total amount to remit with order form $ Due to availability of some items, prior payment is recommended Please note that the sign(s) will be shipped by United Parcel Service (UPS) and cannot be delivered to a Post Office Box. *Signs can be picked up at the ceremony. Please make checks payable to the "State of Indiana". Return completed form and check to: Hoosier Homestead Award Program Office of the Commissioner of Agriculture ISTA Center - Suite 414 150 West Market Street Indianapolis, Indiana 46204-2810 OFFICE USE ONLY
Transaction # Check # Initials ID #

Enclosed you will find a sheet providing examples of the Hoosier Homestead Sign and Certificate.