HISTORIC BRICK WALK PROJECT

ORDER FORM

 

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PURCHASERíS NAME

 

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ADDRESS

 

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CITY/STATE/ZIP

 

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PHONE #                                                                   E-MAIL

 

I would like to:

____bricks @ $100.00 each = $_________ total

 

_____ to become a Historical Society Member:

 

        ___ Individual ($20)          ___ Life/Individual ($250)

        ___ Family ($30)              ___ Life/Couple ($400)

        ___ Sustaining ($100)                ___ Business ($100)

                                        ___ Corp. Partner ($250)

 

I am enclosing my payment of $_________ by:

 

                        ___ Check to the Union County Historical Society

        ___ VISA     ___ MasterCard

 

        Card #_________________________ Exp. ________

        Cardholder __________________________________

 

        Signature:___________________________________

 

I wish the brick to be inscribed as printed:

       (3 lines maximum  14 spaces each)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check your inscription for accuracy. For multiple brick orders, please attach additional inscriptions. The Historical Society reserves the right to approve inscriptions and to refund payments in case the project is cancelled for any reason.

 

PLEASE MAIL FORM AND PAYMENT TO:

Union County Historical Society

P.O. Box 35

Blairsville, GA 30514