Memorial Plaque/Brick Order Form Memorial Plaque/Brick Form 2017 Remember your loved ones with a plaque on the Memorial Wall or purchase a brick for the patio. To have your memorial plaque placed on the wall by the High Holy Days, please have this form submitted no later than August 30, 2017. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Number of Memorial Plaques Price: $500.00 Quantity: Number of Bricks Price: $250.00 Quantity: Please list the name(s) and date of birth and death for the Memorial PlaquePlease list the name(s) for the brickIs 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
