George Washington Carver
Donor Brick Form
Please print and return this page along with your payment to the address below.

 First Name  Last Name Telephone
Address City

State

Zip code

Individuals

(Size 4 inches x 8 inches)

Family Surnames

(Size 4 x 8 inches)

Businesses, Universities/Colleges

(Size 8 x 8 inches)
#______ @$30.00 each for 1 Line of Inscription #______ @$50.00 each for 1 Line of Inscription #______@$100.00 each for 2 Lines of Inscription (no logo)
#_______@$50.00 each for 2 Lines of Inscription #_____@$75.00 each for 2 Lines of Inscription #______@$200.00 each for 2 Lines of Inscription (with logo) Please include logo with order
 Are you a Carver Alumnus? Check here________   #______ @$500.00 each for 2 Lines of Inscription (With logo and metallic lettering)
PRINT IN BLOCK LETTERS A MAXIMUM OF 15 SPACES PER LINE.(SPACES INCLUDE ALL LETTERS, PUNCTUATION MARKS, AND SPACES BETWEEN NAMES).
 

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 BRICK1 LINE 1                              
BRICK 1 LINE 2                              
BRICK 2 LINE 1                              
BRICK 2 LINE 2                              
BRICK 3 LINE 1                              
BRICK 3 LINE 2                              
MAKE CKECKS, MONEY ORDERS OR CASHIER'S CHECK PAYABLE TO:

GEORGE WASHINGTON CARVER MEMORIAL, INC. P.O. BOX 344, FULTON, MISSOURI 65251

email: carvermemorial@yahoo.com