ORDER FORM - Etched Bricks (for "Walkway of Memories")

PLEASE PRINT THIS ENTIRE PAGE, FILL OUT REQUESTED INFORMATION

HONOREE:      
(first line: NAME)
      
(2nd line: NAME)
      
DONOR:      
(your name:)
      
(your address 1:)
      
(your address 2:)
      
(your state zip:)
      
(your pho no.:)
      
(your email:)
      
Brick Cost Each:
$40.00
    
       
Make Checks Payable To:    
  Friends of the Covered Bridge  
Mail To:      
  Sara Kelchner  
  1751 Quisenberry Road  
  Sedalia, MO 65301  
Paid by:
      
 
Personal Check:
 YES (circle if true) Check No.:
 
Cash:
 YES (circle if true)  
Example:Honoree's Name:
JAMES & MARY
(appears on line one of the brick)
 
SMITH
(appears on line two of the brick)

 

 

(example of brick)