Southeast Idaho Veteran's Memorial

PLEASE PRINT CLEARLY                                     ONE BRICK PER FORM

Purchaser's Name:                                                               Cash  $                                

Street of Box No.:                                                                    Check #            $               

City:                                                State:            Zip:                         MO#                   $

Phone:__                                           Signature: __________________________________

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BRICK ENGRAVING INSTRUCTION

You have 2 options for engraved information on the Brick (Please Print Clearly)
Option 1: You have 3 lines to enter 20 letters and numbers of information for each line, including spaces.
Option 2:  You may have the person's Military Service Emblem and three lines with only 12 letters and numbers per
line including spaces.  If you choose this option circle the branch of service below.
Army     Navy     Marines     Air Force     Coast Guard     Merchant Marines

(Please stay within the number of spaces allowed per line:)

                                                                          12                                                20

                                                                         12                                                20

                                                                          12                                                20

Terms:

Since all orders are custom, we do require payment in advance.

Make checks payable to:  Southeast Idaho Veteran's Memorial Fund

Mail to:  Southeast Idaho Veteran's Memorial

P.O. Box 2049, Pocatello, ID, 83206-2049

If you have questions or need help with your order please call one of the following:

  Jack Halpin            208-232--6198
 Stan Brangham      208-237-3607
Will Pretzer            208-233-5970