Please use this form to order your custom Past Eminent Commander Jewel. If you like, you may also e-mail us at info@insignia-emblematic-creations.com for more information.

After completing this form, you will recieve a confirmation email. Please print the email and include it with your payment.

Your personalized jewel will be created after payment is received. Payment instructions are at the bottom of this form and will also be included in your confirmation email.

Please be sure your phone number and email address are accurate so that we may contact you if we have any questions about your jewel.

We thank you for your interest in getting your jewel from Insignia Emblematic Creations.

First Name	*
Last Name	*
Email	*   be sure to enter a valid e-mail address
Address	*
Address 2
City	*
State	*
Zip	*
Phone #	*
Fax

Commandery Name : *  
Commandery Number : *  
(for back of jewel)
Name of Eminent Commander: *  
Date of Service: *  
The cost of the Past Eminent Commander Jewel is
$80.00 plus
$7.95 shipping
$5.28 state sales tax
Total: $93.23.

Price includes engraving and case.

Please forward your payment to:
Insignia-Emblematic-Creations, LLC
P.O. Box 100
Bala Cynwyd, PA 19004