Veterans Bell Tower Memorial Brick Form

Contribute

Brick Order Form

Please complete the following: (Veterans Bell Tower Memorial LLC reserves the right to approve inscriptions.)

First Name: Last Name:

Street Address: City: State: Zip:

Phone: Email Address:

Credit Card Information
Payment Method

Credit Card #:
Numbers only, no spaces please.
Expiration Date:

Order Amount $:
Your card will be billed in U.S.$.

$100 4” x 8”, 3 lines, 14 characters per line

Lettering Information:

$250 8” x 16”, 6 lines, 28 characters per line

Lettering Information:

$500 16” x 16”, 12 lines, 28 characters per line

Lettering Information:

$1,000 24” x 24”, 21 lines, 42 characters per line

Lettering Information:

Additional information and/or corrections you wish to provide us:

Mail to: Veterans Bell Tower Memorial
P.O.Box 90
Pewaukee, WI 53072

Print 2 copies and retain one for your records