Please Complete the form below (printing legibly).
Include a check for $100 made payable to the City of Chino Hills, and mail or deliver to:

Patriot Flag Donation Program
C/O The City of Chino Hills
14000 City Center Drive
Chino Hills, CA 91709

Personal Information

Name*

Phone*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

To Show our gratitude for your generous support of the Chino Hills Patriot Flag Donation Program, the City will display an engraved plaque listing individual donations each year at City Hall. Additionally, donors will receive a certificate of recognition from the Mayor of Chino Hills.

Certificate Information

Name as you would like it to appear on the certificate:*

In the fields below please enter what you would like your engraved nameplate to display. Please make sure to specify the text you prefer. Suggested phrases you may wish to use include "Donated by...", "In Honor of..." or "In Memory of...", etc. A maximum of 3 lines of text is allowed. Please print clearly.

Plaque Information

First Line of Text:(30 Character Maximum)*

Second Line of Text:(30 Character Maximum)*

Third Line of Text:(30 Character Maximum)*