Madison Valley Veterans' Memorial Order Form

Order Form
Eligibility: Veterans who have honorably served in peace or war,
resident or nonresident, living or deceased. Battles, dates and/or
units may also be commemorated. No orders accepted from May 1 - July 4.
Bricks to be dedicated July 4, 2008 at the Memorial in Ennis, Montana.

Make tax-deductible
(Tax ID #68-0580264) Checks/Money Orders Payable:

Madison Valley Veterans' Memorial
P.O. Box 411 ~ Ennis, MT 59729

________________________ _______   __________________________
              First Name            MI                        Last Name
Personal Awards (PH or higher), or KIA if killed in action ______________

_______   __________________   ________________________________
   Rank      Branch of Service          Conflict (If Any), or Years served
and/or _______________________________________________________
          Battle/Date/Unit Categories (3 Lines, Max. 14 Chars. per line including spaces)
Example: Click Here and Note Battle/Date/Unit Categories here in red.

Donor's Name/Phone ___________________________________________

Place this brick with _______________________________

Quantity

Item/Description

Each

Total

_______________

Bench (Includes Miniature Cowboy,
8"x8" brick and 4"x8" brick)

$5,000.00

_______________

Story Plaque

$3,000.00

_______________

Flag Pole

$2,000.00

_______________

Miniature Cowboy

$600.00

_______________

___________

Brick 8"x8"

$1,000.00

___________

_______________

Brick 4"x8"

$100.00

_______________

Gift Certificate

Choose item or amount

_______________

Total

$__________

Print and complete form. Remember to include Check or Money Order. Thank you.

*Order Form* Eligibility: Veterans who have honorably served in peace or war, resident or nonresident, living or deceased. Battles, dates and/or units may also be commemorated. No orders accepted from May 1 - July 4. Bricks to be dedicated July 4, 2008 at the Memorial in Ennis, Montana. Make tax-deductible (Tax ID #68-0580264) Checks/Money Orders Payable: Madison Valley Veterans' Memorial P.O. Box 411 ~ Ennis, MT 59729
________________________ _______ __________________________ First Name MI Last Name Personal Awards (PH or higher), or KIA if killed in action ______________ _______ __________________ ________________________________ Rank Branch of Service Conflict (If Any), or Years served and/or _______________________________________________________ Battle/Date/Unit Categories (3 Lines, Max. 14 Chars. per line including spaces) Example: Click Here and Note Battle/Date/Unit Categories here in red. Donor's Name/Phone ___________________________________________ Place this brick with _______________________________
Quantity	Item/Description	Each	Total
_______________	Bench (Includes Miniature Cowboy, 8"x8" brick and 4"x8" brick)	$5,000.00	_______________
_______________	Story Plaque	$3,000.00	_______________
_______________	Flag Pole	$2,000.00	_______________
_______________	Miniature Cowboy	$600.00	_______________
___________	Brick 8"x8"	$1,000.00	___________
_______________	Brick 4"x8"	$100.00	_______________
_______________	Gift Certificate	Choose item or amount	_______________
		Total	$__________
	Print and complete form. Remember to include Check or Money Order. Thank you.