Memorial Walk Pavers Form Please print these forms and mail with payment to
Brick Orders #4 2007-2008
Stephens County Historical Society 160 N. Alexander Street, Toccoa Georgia 30577
Purchaser (please print) ______________________________________________________
Address __________________________________________________________________
Telephone __ __ __-__ __ __-__ __ __ __ Email _________________________________
Form of payment Check ___ Credit Card ___ Card type Visa ___ MasterCard ___
Name on Card __________________________________________________________
Account Number ___ ___ ___ ___-___ ___ ___ ___ -___ ___ ___ ___-___ ___ ___ ___
Expiration date _________________________________________________________
Amount to be charged ____________________________________________________
Security Code (last 3 digits on back of card in signature line) ______________________
Signature _________________________________ Date ______________________
You may wish to call your payment in to the museum, please contact Sybil or Brenda. 706-282-5055
Regular Pricing: The price of one brick is $100.00 each. After the first brick purchase you may
purchase additional bricks at $50.00 each.
Note: Maximum of 14 characters and spaces per line: 1, 2, 3 lines available. Please print your message
ABCDEFGHIJKLMNOPQRSTUVWXYZ 1234567890 - ' * " ; : , . & ( )
(each character is a space and a space is counted as one of 14 characters)
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| Item Name: Brick Paver Item Number: Price: $100.00
|
Item Name: Second, Third, etc.. Bricks at $50.00 each Item Number: Price: $50.00
|