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MEMORIAL
RESTORATION AND REDEDICATION
Click
here for Artist rendition of The Circle Of Honor
Brick
Order Form
Instructions:
Print your message in the boxes below exactly as you want your
brick to appear. Be sure to
leave a blank box between words. Each
line accommodates a maximum of 15 characters, including blank boxes
and punctuation (commas, periods, hyphens).
If ordering more than one brick, photocopy this form or use a
separate sheet of paper.
LINE 1:
LINE
2:
LINE
3:
(Use LINE 4 and 5 for
8”X 8” X 2”
bricks only)
LINE 4:
LINE 5:
Name________________________________________________
Phone___________________
Address_______________________________________________________________________
City, St,
Zip____________________________________________________________________
q 4”
x 8” x 2” Brick - $100
enclosed
q
4” x 8” x 2” Brick
- $25 enclosed with 3 additional payments of $25 in 3, 6 and 9
months.
($25 x 4 = $100) Bricks
will be inscribed when the full amount is paid.
q 8”
x 8” x 2” Brick - $175
enclosed
q Visa
Card # ________________________________________ Exp.
Date______________
q Mastercard
Card #___________________________________ Exp.
Date______________
q Signature
(Required for Credit Card transactions) _________________________________
Please
make checks/money orders payable to: 11th
ACVVC. Mail this form
with your check, money order, or credit card (no cash) to:11th
ACVVC Treasurer, C/O Ollie Pickral, 571 Ditchley Rd, Kilmarnock, VA 22482
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