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)
q q q q q q q q q q q q q q

LINE 2:  BRANCH OF SERVICE (or name - see Line 1)
q q q q q q q q q q q q q q

LINE 3:  YEARS OF SERVICE (If years of service are unknown, you may list the name of the War or Conflict)
q q q q q q q q q q q q q q

ORDERED BY:

 

NAME:

 __________________________________________________________________

 

ADDRESS:

 __________________________________________________________________

 

CITY/STATE/ZIP:

 __________________________________________________________________

 

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