VETERANS MEMORIAL
HIGHLAND COUNTY
BRICK ORDER FORM / DONATION FORM
Print the information in the boxes below exactly as you want your brick to appear. Be sure to leave a blank box between words. Each line accommodates 13 characters, including blank boxes and punctuation (commas, periods, hyphens). If ordering more than one brick, please photocopy this form or use a separate sheet of paper. Donations to help with the cost of maintaining the memorial are also appreciated.
LINE 1: NAME OF VETERAN (If name is more than 14 characters, you may use Line 1 & Line 2 for the name)
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LINE 2: BRANCH OF SERVICE (or name - see Line 1)
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LINE 3: YEARS OF SERVICE (If years of service are unknown, you may list the name of the War or Conflict)
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ORDERED BY: | |
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NAME: | __________________________________________________________________ |
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ADDRESS: | __________________________________________________________________ |
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CITY/STATE/ZIP: | __________________________________________________________________ |
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PHONE: | __________________________________ |
Number of paver(s) _______ x $100 each = $ _____________
Additional donation $ _______________ (Optional)
Please make checks or money orders for the above amount(s) payable to:
Highland County Veterans Memorial
Mail this form with your check or money order to:
Highland County Veterans Memorial
P. O. Box 595
Monterey, VA 24465