Memorial Plaque/Brick Order Form – Houston Congregation for Reform Judaism

Remember your loved ones with a plaque on the Memorial Wall or purchase a brick for the patio.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Number of Memorial Plaques Quantity
Price: $500.00
Number of Bricks Quantity
Price: $250.00
Please list the name(s) and date of birth and death for the Memorial Plaque
Please list the name(s) for the brick
Is this brick in honor or in memory of someone?
- In honor of
- In memory of
Would you like to add a 3% additional fee to help us offset credit card processing charges on your donation?
- yes
- no
Coverage for 3% Credit Card Processing Charge
Price: $0.00
Total
$0.00