ORDER FORM District 25th Jubilee Souvenirs Your Name * Please enter your full name (first name and family name), please. Your Lodge (please indicate below if MARK or RAM) 1587 La Marque d'Alliance 1603 Les Disciples de Salomon 1624 La Marque d'Union 1653 Mark L'Espérance 1673 Mark of Enterprise 1753 Mark Ter Duinen 1815 La Marque de Lorraine 1875 Mark Prins van Oranje 1900 Mark Jeanne d'Arc 1928 Mark John of Gaunt 1966 Flanders Mark 1983 Belgian Installed Mark Masters Other Your Lodge (please indicate below if MARK or RAM) MARK or RAM? MARK RAM Your Email Address * Which District 25th anniversary souvenir do you wish to order? * logo required delete delete_solid move drag clear noclear duplicate copy clone_solid clone tooltip tooltip_solid forbid checkmark image checkmark_circle checkmark_square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key keyalt_solid keyalt keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms highrise mailchimp feed align_right align_left button browser cloud_download_solid cloud_download cloud_upload_solid cloud_upload cloud_solid cloud shuffle swap dropper_solid tint pallet_solid pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock_solid lock magic_wand dollar_sign percent notification_solid notification external_link pageview_solid pageview settings_solid settings stamp support text_solid text text3 unfold_less unfold_more work_solid work white_label zoom_out maximize minimize authorize activecampaign aweber campaignmonitor constant_contact getresponse googlesheets building hubspot icontact mailpoet paypal icon sendinblue sendy salesforce salesforcealt stripe stripealt twilio woocommerce wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Zapier Preview Back Locked Unlock District pin (€5.00) District mug (€15.00) Both - District Pin & Mug (€20.00) Quantity Your postal address Your postal address Your postal address Your postal address Postal code Postal code City City Country - change if not Belgium Change if not Belgium! Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country - change if not Belgium Special delivery requirements. Please note that delivery will be in person after the Jubilee Meeting, indicate if you wish to have different delivery arrangements or delivery by postal service. If you are human, leave this field blank.