VET Brick Purchase Form

Regular Brick 4x8 $100*, Large Brick 8x8 $175*.
Date

Month Day Year
Date
Name of Purchaser

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Email
example@example.com
Number of Bricks
Amount Enclosed
I wish to donate to the Brick Scholarship fund. Donations to this fund benefit individuals who need assistance purchasing a brick for their loved one. Yes, I want to group brick with others. Must submit forms and payment together.
Information to be Engraved:
Name (25 Characters Max)

First Name Last Name
Branch & Rank (20 Characters Max)
Years of Service (9 Characters Max)
Choice of Emblems (Pick One)

Army Marine Corp Navy Air Force Coast Guard
Large Brick (Choose Additional Flag Emblem If Interested)

American Flag (Large Brick Only) Military Specialization (Large Brick Only) MIA/POW (Large Brick Only)
If you need assistance or help verifying veteran's information,

please contact Cathi Osentoski, (810) 629-2261 or Cosentoski@CityOfFenton.org
*Additional fees apply for online purchase.
Brick Payment
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Regular Brick $ 103.30

Quantity
Item subtotal: $ 0.00

Large Brick $ 180.53

Quantity

Total $ 0.00
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