To: Iron County Board of Commissioners

Courthouse Memorial Park Order Form

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Courthouse Memorial Park Brick Project

2 South Sixth Street, Suite 7

Crystal Falls, MI 49920-1413

Checklist:

______I wish to participate in the Courthouse Memorial Park by purchasing a brick.

______My $50.00 check payable to the County of Iron Brick Project is enclosed.

I wish to have the following engraved on the 4" x 8" Brick:

(Note: Maximum 21 characters per line including spaces and punctuation with a four-line maximum. Engraving Limited to Former or Current County of Iron Employee: Name, Position, Date of County Service or Life, and Location Representation.)

In Honor of or In Memory of or In Loving Memory of ~ is also permitted.

Line 1: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 2: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 3: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 4: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

______I do not wish to purchase a brick but I would like to donate to this project.

Please Print:

Contact Name: _______________________________________

Address: _______________________________________

_______________________________________

Telephone Number: _______________________________________

Email Address: _______________________________________

Comments, if any: ______________________________________________________

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