WFEM LEGACY STONE ORDER FORM

WFEM LEGACY STONE ORDER FORM
DONOR INFORMATION
Heading
NAME
ADDRESS
CITY
STATE
ZIP
PHONE
EMAIL
example@example.com
$300 - 6" x 12" Walkway Brick - 3 Lines of text with 16 characters per line

$500 - 12" x 12" Walkway Brick - 6 Lines of text with 16 characters per line
LINE 1
LINE 2
LINE 3
LINE 4
LINE 5
LINE 6
SPECIAL REQUESTS
PLEASE REVIEW BEFORE SUBMITTING

TO ENSURE THE CORRECT SPELLING

PAYMENT DUE BY APRIL 1st

CREDIT CARD PAYMENT (OPTIONAL) BELOW
Payment Options - Please Select One

CheckSquare

Legacy Stone Options - Please Select One

6" x 12" Legacy Stone - $30012" x 12" Legacy Stone - $500
Total
Bank Name*
Check Number*
REMIT TO: WISCONSIN FIRE & EMS MEMORIAL

PO BOX 248 Wisconsin Rapids, WI 54495
LEGACY STONE PLACEMENT CEREMONY

2nd Saturday of June at 10:30 am
FOR INTERNAL USE BELOW
Date Received:
Location Placed:
Family Notified:
Should be Empty:

DONOR INFORMATION