Brick Order Form

"*" indicates required fields

Minimum donation is $40 per brick. All proceeds will go toward financing of the Veterans Memorial. Just complete the order form below. Examples for filling out forms are on bottom of this form. Please feel free to call the office at 812-689-7165 with any questions.

Name*

First Last

Home Phone*

Second Phone

Address*

Street Address City State ZIP Code

PRINT INDIVIDUAL NAME OR FAMILY (LEAVE BLANK SPACES BETWEEN NAMES) NO PUNCTUATION. PLEASE PRINT CLEARLY

Each brick (4″ x 8″) will have 3 lines of inscription with 13 characters MAXIMUM per line (including spaces, etc.). Please fill in the table below with your information. Please refer to example if you need help. The information will automatically be centered on the brick. All orders are final. No cancellations or refunds can be accepted.

IS APPLICANT A VETERAN?

Yes

Please list information on MIA, POW, KIA

Brick Type (Please Check)*

Single

Double

Brick Line 1

Brick Line 2

Brick Line 3

Brick Line 4

Brick Line 5

Brick Line 6

Donation Check Amount

Please enter a number greater than or equal to 0.

I DON’T WANT TO BUY A BRICK, BUT WOULD LIKE TO DONATE TO THE VETERANS MEMORIAL PROJECT. PLEASE ENTER CHECK AMOUNT.

Bricks will not be ordered until donation is received

MAKE CHECKS PAYABLE TO:
RIPLEY COUNTY MEMORIAL FUND, PO BOX 235, VERSAILLES, IN 47042

Brick Order Form

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