Address:______________________________________ City:_______________________________

State:______________________________ Zip:__________ Phone:(_____)____________________

SCV Camp:__________________________________ Location:_____________________________

Confederate Veteran's Name:____________________________ Rank:_________________ ______

Unit:________________________________ _________ Born:____/____/____ Died:____/____/____

Location of Grave (Include name of cemetery, city, county & state):___________________________

________________________________________________________________________________

________________________________________________________________________________

Services Performed (Attach Additional Sheets If Needed):

1. Visits Per Year: ______________ Time Period Grave Has Been Tended: ____________________

2. Flag Placed On Grave For Confederate Memorial Day: ________Yes  _________No

3. Marker On Grave Indicating CSA Service: ________Yes  _________No

4. Other Services Performed: _________________________________________________________

________________________________________________________________________________

I affirm that all the information here is true and accurate. I agree to faithfully care for and protect this Confederate Veteran's grave in accordance with the Guardian rules (as specified in SC Division Administrative Order 93-1) for as long as I am able. In the event I am no longer able to carry out my duties, I shall notify the Guardian Review Committee immediately.

Signature:_______________________________________     Date: ____/____/____

-------------------DO NOT WRITE BELOW THIS LINE -- FOR COMMITTEE USE ONLY! -------------------

Guardian Review Committee Action:

I.    Application Approved __________ Disapproved___________ For Full Guardian.

II.   Application Approved __________ Disapproved___________ For Guardian Pro Tem.

III.  Wilderness Grave: Approved __________ Disapproved___________

IV.  Pro Tem Period:  ______________ Months:   From ____________________ to ____________________

Committee Member Signature: ________________________________________   Date: ____/____/____