Clermont County Vietnam Veterans Chapter 6 4 9

MEMORIAL COMMEMORATIVE BRICK ORDER FORM

Commemorative Bricks May Be Purchased To “Honor” Anyone You Choose

Single Brick - $ 30.00

Maximum Three (3) Lines. Fourteen (14) Characters Per Line

( Includes Spaces And Periods )

Please Submit A Self Addressed Stamped Envelope To Receive The Location Placement Of You Brick

** Note **

Location & Placement Of The Brick Is At The Discretion Of The Memorial Committee

Time Of Placement Is Dependent On Weather Conditions ( Rain / Snow / Ice, ( etc. )

The Memorial Committee Reserves The Right To Approve All Wording

Please Allow 30 – 60 Days For Engraving And Placement Of Bricks

Sample Brick

 Your  Brick  Will  Read

Brick Purchaser’s Information

Name :

Address :

City : State : Zip :

Phone # ( ) Cell Phone # ( )

E-Mail Address :

Payment Received By :

Make Checks Payable To : V.V.A. Chapter 649 Memorial Fund and include remittance with
legible order form to avoid error.

Mail To : Vietnam Veterans Of America, Chapter 649 P.O. Box 426 Batavia Ohio 45103

Check Number & Amount Cash Amount

Credit Card : Visa / Master Card Card Number

Expiration Date / Card Holders Signature

Line Shown Below Is For Chapter Use Only

Column :________    Row :________