SIDEWALK PAVER ORDER FORM 8X8" FOR POST ENTRANCE
Contact Information:  Person Placing Brick Order           Control #                                                    
Name:                                                                            Telephone #                                               
Address:                                                                         E-MAIL                                                        
                                                                                                                   
State:                                 Zip Code:                         
Each brick can be engraved with one emblem and up to 6 lines of of text.  Each line can contain up to 20
characters (letters, punctuation, spaces).  All Letters will be engraved in UPPER CASE. 

                                                                                 
Brick # 1    Emblem             AL                                  AUX                                      SAL
Line 1 Line 2 Line 3 Line 4 Line 5 Line 6
Cost per Brick                   $200.00        No. of Bricks Ordered:                           Subtotal:$                           
                                                                                                                                 Total:$                           
Make Checks Payable to:                                                      Received by:                                                     
Hardin Post 113 Building Fund                                                   Check #                                                       

You will receive a receipt by E-mail (If provided) or "Snail Mail" with the inscription as you have entered.
PLEASE REVIEW AND SUBMIT CORRECTIONS IMMEDIATELY!  CORRECTIONS CAN BE SUBMITTED VIA E-MAIL AT
leroyhsmith@comcast.net or by telephone 270-304-5060.