1. Last Name: ____________________________________________

   Given Names: __________________________________

   _____ Miss   _____ Ms.   _____ Mr.   _____ Mrs.

   Address _____________________________________________________________

   Apt. ____________   City _________________________________

   Postal Code ________________    Telephone (_______) _____-________

2. OCCASION:

   _____ Birthday	__________ Age	____________________ Date
   _____  Wedding Anniversary	__________ Years	____________________ Date

3. DATE OF CELEBRATION:_______________________________

4. CHOICE OF LANGUAGE:__________ English   __________ French

5. SEND MESSAGE TO:

   ______________________________________________________
   Name

   ______________________________________________   Address

   _____________________ Apt.

   _________________________________________________________
   City

   ______________________________ Province

   ______________________ Postal Code

   Telephone (_______) ________-_____________

6. REQUESTOR'S NAME: ________________________________________________
   

   Telephone: (________) ________-______________

Please complete and return this form to the Anniversary Section, Rideau Hall, 1 Sussex Drive, Ottawa, Ontario, K1A 0A1 or by fax at (613) 990-7636. Also note that messages from The Queen are sent to Canadians who are 100 years of age or older and couples who have been married for 60 years or more (please include appropriate documentation). If you have any questions, please contact the Anniversary Section at (613) 993-2913 or (613) 993-8164 or by e-mail at anniv@gg.ca.