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Purchaser InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* In honor or memory of:Comments:Payment InformationDonation Amount*$25$50$100$250$500Other AmountWhen you donate $500 or more, you qualify to have an inscription made on the Friends of the Rangers Program tablet for the current year. You also have the option to receive up to two stones.Other Amount* Choose amount of stones to receive.*012Ranger's InformationName* First Middle Last Suffix Limit unit to Appear (20 Characters or less including spaces)*Click here for a list of appropriate unit designationsSecond Stone Name* First Middle Last Suffix Second Stone Limit unit to Appear (20 Characters or less including spaces)*CommentsQualification CriteriaCheck any that apply Graduate of the U.S. Army Ranger School Served in a provisional or operational LRP/LRRP company during the Vietnam War Served in an operational Ranger unit during peace or wartime Attached to Ranger Unit during combat operations Awarded the U.S. Army Ranger Tab by General Executive Order for: World War II Ranger Battalions Merrills Marauders (5307th Composite Unit-Provisional Ranger Infantry Companies (Airborne) of the Korean War Proof of Service:Check any that apply DD Form 214 Ranger School graduation diploma Special orders awaiting Ranger qualification or service with a Ranger unit Please upload a copy of the above Proof of Service here: Drop files here or * Checking this box means you agree with the following: The information I've provided on this form is correct to the best of my knowledge. I understand that knowingly and willfully providing a false statement or misrepresenting the qualifications of the individual to be engraved on the National Ranger M emorial Foundation Monument is a violation of Georgia Code 16-10-20 and Section 1001, Title 18, U.S. Code and subj ects me to prosecution punishable by a fine, imprisonment, or both. Individual stones cost $295.00 and can be paid for on-line with your credit card. You will be notified of your acceptance through a return e-mail confirmation. National Ranger Memorial Foundation, Inc. P.O. Box 53369 Fort Benning, GA 31995Payment Method*Credit CardCheckCredit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Total $0.00 CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
