HISTORIC BRICK WALK PROJECT

ORDER FORM

_________________________________________________________

PURCHASER’S NAME

_____________________________________________________________________________________

ADDRESS

_____________________________________________________________________________________

CITY/STATE/ZIP

_____________________________________________________________________________________

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