MOSHANNON VALLEY VETERANS MEMORIAL
PERSONALIZED BRICK ORDER FORM
Paver installed on the wall $125.00 each
Paver installed on sidewalk in mortar $100.00 each
Paver installed in sand $50.00 each
Type Styles : 2      ABC      123
Living      Deceased
Dealer Name/ Address:
Swisher Concrete Products, Inc.
P.O. Box 55
Clearfield, Pa 16830
(814) 765-9502
Ordered By:
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Ctiy, State, Zip: ______________________________________________________________
Phone:
15 Characters - Including Spaces - 3 LINES AVAILABLE FOR PRINT
     NAME
     BRANCH
     SERVICE DATES
 
Mail To:

Veterans Memorial
c/o James Washburn
P.O. Box 1
Philipsburg, PA 16866

*Make all checks payable to : VMBF

Thank you for your order!