---- MEMORIAL BRICK Order Form----
Complete
and mail with your $25.00
payment to the below address
Checks
payable to City of Warsaw-Mainstreet Brick fund
Att:
Wayne Rassman
City of Warsaw
Memorial Bricks
102
W. Market St. PO Box 785 Warsaw, Ky. 41095
Questions
email :
Name ___________________________________________________
Address __________________________________________________
City_____________________ State_______ Zip______________
Signature__________________________________________________
Details
for inscription on the Memorial Brick
Purchaser's Name_______________________________________________________
Address_________________________________________
Phone
_______________
City/State
______________________________________
Zip Code _____________
Only
14 spaces per line
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Print individual
name or family name (leave blank spaces between names). Commas and periods count
as a space.
Paid Amount $____________