PARRY MCCLUER MEMORIAL BRICK FUND
NAME_________________________________________________________________________
ADDRESS_____________________________________________________________________
PHONE NUMBER (HOME)_________________________ (WORK)_____________________
Inscription for your brick: PLEASE PRINT CLEARLY - TWO LINE LIMIT: 14 characters or numbers per line only, including spaces and punctuation. Symbols count as 3 spaces.
BRICK INSCRIPTION:
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I WANT AN ADDITIONAL BRICK: Yes____ No____
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Complete this form and return it with your donation in the form of check or money order in the amount of $25.00 (per brick). Make payable to:
PARRY MCCLUER MEMORIAL BRICK FUND
Return the completed form and check or money order to:
Parry McCluer Memorial Brick Fund Attn: PMHS SCA 2329 Chestnut Avenue Buena Vista, VA 24416 (540-261-2127)
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