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| Her Majesty Queen Margrethe II of Denmark, Protector |
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| The Danish Immigrant Museum 2212 Washington Street P.O. Box 470 Elk Horn, Iowa 51531-0470 712.764.7001 © Since 1983; All Rights Reserved |
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| WALL OF HONOR FORM Print and complete this form; mail with payment to: The Danish Immigrant Museum The Danish Immigrant Wall of Honor 2212 Washington Street P.O. Box 470 Elk Horn, Iowa 51531-0470 _________________________________________________________________________ Immigrant Information: Include biographies, documentation, photos, and such. These may be included with this form or sent as E.Mail attachments to: development@danishmuseum.org Name of Immigrant or Married Couple: ___________________________________________ Year of Immigration:: ___________________________________________ Primary Place of Settlement in U.S. (city or town & state): ______________________________ Please note: This is how the name(s) will appear on the name plaque. Names must be limited to 40 characters, including spaces. No titles may be used. Married couples will be on one plaque, unless otherwise specified. For assistance or questions please contact Deb Larsen at 1.712.764.7001. Include biographies, documentation, photos, and such. These may be included with this form or sent as E.Mail attachments to: development@danishmuseum.org Date of Birth: ______________________________________ Place of Birth: ______________________________________ Father: ______________________________________ Mother: ___________________________________________ Date of Marriage: ______________________________________ Place of Marriage: ___________________________________ Name of Spouse (include maiden name of wife): _________________________________ Date of Death: ______________________________________ Place of Death: _____________________________________ Occupation: ______________________ Religion: _________________ Military Service: ______________________________________ Other Places Lived: ________________________________________________________ Names of Children (Birth Year Optional): ____________________________________ _________________________________ ____________________________________ _________________________________ ____________________________________ _________________________________ ____________________________________ _________________________________ Emigrated From: ___________________________ On (Vessel): __________________________________ Port of Entry: ____________________________________________________________ Reason for Emigration: ___________________________________________________ Other Relatives Who Immigrated: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Additional Information & Family History Highlights: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (Continue listing any information on the back of form, or; as an additional document when needed.) _________________________________________________________________________ Date: _____________________ Your (Sponsor) Name: _____________________________________________________ Relationship to Immigrant: _________________________________________________ Mailing Address: _________________________________________________ City: _______________________________ State: _________ ZIP: _________ Phone: ___________________________ E.Mail: _______________________ Please complete a separate form for each name. _________________________________________________________________________ Information Provided By: Same As Above: ___________ Name (When Different): _______________________________________________ Relationship to Immigrant: _________________________________________________ Mailing Address: _________________________________________________ City: _______________________________ State: _________ ZIP: _________ Phone: ___________________________ E.Mail: ______________________ _________________________________________________________________________ Sponsors Who Contributed to this Wall of Honor Nomination (If Applicable): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _________________________________________________________________________ Payment Information: ($250 per name) Please complete a separate form for each name. [ ] A check or money order for $250 is enclosed. [ ] I authorize my credit card to be billed for $250. MasterCard _______ Visa _______ Card # __________________________________ Exact Name On Card: ________________________________________________ Expiration Date: ___________ Signature: ___________________________________________ (Date) _________ The Danish Immigrant Museum is a 501 ( c) 3 non-profit organization. Your gifts and contributions are tax deductible to the extent allowed by law. Please contact your tax advisor. _________________________________________________________________________ For Office Use Only: Date: _____________________ ID #: ________________ Column: ____________ Row: ______________ Initials: _____________ |
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