In honor or loving memory of *

Honoree Name *

Individual(s) or Organization Lighting the Star *

Desired Star Lighting Date *

Certificate Message *

Name of Buyer (First & Last name) *

Phone Number *

Email Address *

Mail Certificate to (Street Address) *

Country * Enter required value United States Canada 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 Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo Democratic Republic of Cook Islands Costa Rica Coted Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands 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 Mc Donald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isleof Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Democratic Peoples Republic Korea Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic 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 Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin 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 Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic 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 Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands British Virgin Islands US Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Sark

State/Province *

City *

ZIP/Postal Code *

Final Acknowledgement (Typed Signature) *

Shared Lighting Notice: Please note that standard nightly lightings may include multiple dedications on the same evening. Your tribute will be recognized, but the Star may also be lit in honor of others. Lighting Color: While the default color is white, the Star's color on your selected date may vary, depending on whether a custom color lighting has already been scheduled. Standard lightings do not include a custom color selection. Submission Deadline: To ensure your lighting request is scheduled, please submit your request at least 7 days in advance of your desired date. Late Requests: Requests submitted fewer than 7 days before the desired date may still be accommodated, but cannot be guaranteed due to operational constraints.

**PLEASE REVIEW PURCHASE**

**TYPED SIGNATURE**