Instructions:
Use the print utility on your browser to print out this form. Please type or print the information clearly. Mail the completed form to:
Sarah Mountain
Office for Parish Life
300 Wyoming Avenue
Scranton, PA 18503

          Recommendation for the
Bronze Pelican Emblem

 

CANDIDATE  

NAME____________________________________________________     

NAME OF SPOUSE_______________________________________  

ADDRESS________________________________________________   

CITY_______________________


STATE_______  ZIP____________

 

PARISH AND PARISH

TOWN_________________________________________________________________________________________

ARCHDIOCESE/DIOCESE

OF_________________________________________________________________________________________

REGISTERED IN SCOUTING AS____________________________________   

COUNCIL_________________________________________  

OCCUPATION AND EMPLOYER______________________________________________________________________________________

TELEPHONE NUMBER – RESIDENCE___________________________________  

OFFICE_______________________________________

PARISH APPROVAL  

On____________________________, the candidate’s pastor _______________________________________ approved the candidate as worthy of  receiving this emblem.

Signed__________________________________________________________________

*Please print the date and Pastor’s name and then have the pastor sing the last line.

 

RECOMMENDED BY  

Name_______________________________________________  Home Phone_______________________

Work Phone___________________  

Address_________________________________________  City___________________________  State______

Zip______________________  

Date Submitted____________________________________