Century Patch Member Certification

Province:   ___________________________________________________________________________

Name:  ______________________________________________________________________________

Address:  ____________________________________________________________________________

City:   _______________________________________________________________________________

Province or State:   ___________________________________________________________________

Postal Code or Zip Code:     ____________________________________________________________

When 10 Samborees have been attended you will qualify for a  Century Patch. Mail or present this form to your Provincial or State Director.

            Samboree                           Location                               Date                      Verification Signature

1   ___________________________________________________________________________________

2   ___________________________________________________________________________________

3   ___________________________________________________________________________________

4   ___________________________________________________________________________________

5   ___________________________________________________________________________________

6   ___________________________________________________________________________________

7   ___________________________________________________________________________________

8   ___________________________________________________________________________________

9   ___________________________________________________________________________________

10  __________________________________________________________________________________

How many Samborees?  Circle one:   10    20    30    40    50    60    70    80