Please complete ALL of the following required information in order to receive an official certificate commemorating your special achievement.

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Recipient Information
First Name:
Last Name:
Email Address:
OGA (GHIN) Member #:
Mailing Address:
City:
State:	Alabama Alaska Alberta Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Island Virginia Washington West Virginia Wisconsin Wyoming
Postal Code:
Achievement Information
Date Occurred:	mm/dd/yy
Golf Course:
Witnessed By:
Accomplishment:	Select... Hole-In-One Double Eagle Shot My Age
Hole Number:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Yardage:
Club Used:	Number: 1 2 3 4 5 6 7 8 9 Sand Lob Pitching Gap Other Type: Wood Iron Wedge Hybrid
Date of Birth:	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959
Score:
Additional Information
Comments or Additional Information:
	I hereby give the OGA permission to use this information in any of their publications and/or on their website.
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