| FIRE AMBULANCE MEMORIAL BRICK |
| Use the browser's print method to print this form; text size-medium |
Your Brick or Bricks will be placed in the foyer of the new Emergency Services Building. Cost $125.00 per Brick.
| Person or Firm making the Purchase: | Name:____________________________ |
| Address:___________________________ | |
| Address:___________________________ |
In the boxes below put the names that you want. They need to be exactly the way you want them to appear on the brick. A box will be used for any blank spaces that are needed. Each brick will have 3 lines with 14 spaces. The bottom of this form will be submitted to the brickmaker.
Payment Record: You may pay in a pattern that totals $125; This form will provide a record:
Make checks payable to: Primghar Emergency Service Building Fund
| Send form and payment to: | Maureen Thompson PO. Box 62 Primghar, IA 51245 Telephone: 712-957-6795 |
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This form is only for the purchase of Bricks. Any other donations will be handled separately.