NC Gov. Cooper: Letter Request Form

REQUESTER INFORMATION

Requester Name *

Requester Organization/Agency *

Requester Phone *

Please format as XXX-XXX-XXXX.

Requester Email *

DELIVERY INFORMATION

Mailing Address (where the completed document should be mailed):

Recipient *

Organization (if applicable)

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Pick Up? *

If the option is available, would you like to pick up the letter from the Administration Building (116 W. Jones St., Raleigh, NC) instead of having it mailed?

Yes

HONOREE/EVENT INFORMATION

Birthday (for individuals turning 80 or older)

Honoree Title: *

Honoree First Name: *

Honoree Middle Name:

Honoree Last Name: *

Honoree Suffix:

Honoree Address (to be included on the letter):

Honoree’s Full Name (exactly as it should appear on the letter) *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Date of Birth *

Month

Day

Year

Age to be Celebrated: *

Additional Information about the Event/Honoree (optional):

Church/Organization Anniversary

Full Name of Church/Organization: *

Pastor/Organization Leader Job Title or Position: *

Pastor/Organization Leader Title: *

(ex. Dr., Ms., Mr., Rev., etc.)

Pastor/Organization Leader First Name: *

Pastor/Organization Leader Middle Name:

Pastor/Organization Leader Last Name: *

Pastor/Organization Leader Suffix:

Church/Organization Address (to be included on the letter):

Pastor/Organization Leader Full Name (exactly as it should appear on the letter) *

Full Name of Church/Organization (exactly as it should appear on the letter) *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Date of Event: *

Anniversary to be Celebrated: *

(Example: 140th anniversary of organization’s founding)

Additional Information about the Event (optional):

Eagle Scout/Gold Award

Honoree First Name: *

Honoree Middle Name:

Honoree Last Name: *

Honoree Suffix:

Honoree Address (to be included on the letter):

Honoree’s Full Name (exactly as it should appear on the letter) *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Troop Number: *

Ceremony Date (if the date has not passed):

Additional Information about the Event/Honoree: *

Please provide information that describes how or why the honoree qualifies for this award.

Family Reunion

Family Name (exactly as it should appear on the letter): *

Reunion Anniversary to be Celebrated (if applicable):

Example: 30th Annual

Event Date: *

Additional Information about the Event (optional):

High School Reunion

Full Name of High School: *

Graduation Year (if applicable):

Reunion Anniversary to be Celebrated: *

Example: 50th Class Reunion

Date of Event: *

Additional Information about the Event (optional):

Military Retirement

Military Branch: *

Honoree Military Title: *

Honoree First Name: *

Honoree Middle Name:

Honoree Last Name: *

Honoree Suffix:

Honoree Address (to be included on the letter):

Honoree’s Full Name (exactly as it should appear on the letter) *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Years of Service: *

Ceremony or Retirement Date (preferred date to be included on letter): *

Letter Presentation Date (if applicable):

Additional Information about the Event/Honoree (optional):

Royal Ranger Award

Honoree First Name: *

Honoree Middle Name:

Honoree Last Name: *

Honoree Suffix:

Honoree Address (to be included on the letter):

Honoree’s Full Name (exactly as it should appear on the letter) *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Outpost Number: *

Ceremony Date (if the date has not passed):

Additional Information about the Event/Honoree (optional):

State Employee Retirement

Full Name of Honoree Organization/Agency/School: *

Honoree Job Title or Position: *

Honoree Title: *

(ex. Dr., Ms., Mr., Rev., etc.)

Honoree First Name: *

Honoree Middle Name:

Honoree Last Name: *

Honoree Suffix:

Honoree Address (to be included on the letter):

Honoree’s Full Name (exactly as it should appear on the letter) *

Full Name of Organization/Agency/School (if applicable, exactly as it should appear on the letter)

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Years of Service: *

Ceremony or Retirement Date (preferred date to be included on letter): *

Additional Information about the Event/Honoree (optional):

Wedding Anniversary (for 25 years or more)

Spouse 1 Title: *

Spouse 1 First Name: *

Spouse 1 Middle Name:

Spouse 1 Last Name: *

Spouse 1 Suffix:

Spouse 2 Title: *

Spouse 2 First Name: *

Spouse 2 Middle Name:

Spouse 2 Last Name: *

Spouse 2 Suffix:

Couple’s Address (to be included on the letter):

Couple’s Names (exactly as they should appear on the letter) *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Date of Event: *

Anniversary to be Celebrated: *

(Example: 30th)

Additional Information about the Event (optional):

Welcome Message

Full Name of Event's Host Organization/Agency: *

Host Organization/Agency Leader Job Title: *

Host Organization/Agency Leader Title: *

(ex. Dr., Ms., Mr., Rev., etc.)

Host Organization/Agency Leader First Name: *

Host Organization/Agency Leader Middle Name:

Host Organization/Agency Leader Last Name: *

Host Organization/Agency Leader Suffix:

Organization/Agency Address (to be included on the letter):

Host Organization/Agency Leader Full Name (exactly as it should appear on the letter) *

Full Name of Host Organization/Agency Full Name (exactly as it should appear on the letter)

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Title/Theme of Event (if applicable): *

(Example: 30th Annual Meeting of the Organization of North Carolina – North Carolina: The State Where We Live)

Date of Event: *

Please give a detailed description of the event and its host and/or sponsoring organization:

Other

Full Name of Organization/Agency Being Honored (if applicable): *

Honoree Job Title or Position:

(if letter is for an organization, honoree should be the organization leader – please include his/her job title)

Honoree Title: *

(ex. Dr., Ms., Mr., Rev., etc.)

Honoree First Name: *

Honoree Middle Name:

Honoree Last Name: *

Honoree Suffix:

Honoree’s Full Name (exactly as it should appear on the letter) *

Full Name of Organization/Agency (if applicable, exactly as it should appear on the letter)

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Date of Event (if applicable):

Please give a detailed description of the event, individual, or organization you would like recognized and why. *

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