box.gif (166 bytes)                             Vietnam Veterans of Westmoreland County
                                                P.O. Box 284
                                          New Stanton, PA 15672

Memorial Brick Order Form

Date: ___________________________________  Check # ___________________________

Please make check payable to
V.V.W.C. Memorial Fund 

Please Print Clearly

Name:  
_____________________________________________________________________
Address:  
_____________________________________________________________________
 
_____________________________________________________________________________
 
_____________________________________________________________________________
Phone:  
_____________________________________________________________________

By your signature, you are verifying the information is correct and is how you want it to appear on the brick.  Spaces count as one of the 12 letters per line.   Commas, periods, etc.. do not count.
Price per brick $150.00 

 
 		                      
 
 		                      
   
 		                      

 

Signature: ____________________________________________________________________

For a Veteran's name to be inscribed on a memorial brick a DD:214 form is required for verification that they were in country on a certain date.

For more information contact Bill at 724-872-4749