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Liberty Regional Medical Center

Memorial Garden Brick Campaign

Liberty Regional Medical Center is sponsoring a brick campaign to raise funds for the Liberty Regional Memorial Garden. Please join us by purchasing a piece of the Memorial.

Each personalized engraved brick measures 4x 8 and allows for 16 characters per line including spaces and punctuation.
To order, complete the Engraving Lines below (no more than 16 characters per line). Your credit card will be charged $50 for this order.
Purchaser
* Name
* Address
  Home Phone
  Work Phone
  Cell Phone
  Email
Engraving
All lines will be centered. Limit each line to maximum of 16 characters including spaces and punctuation.
* Line 1
  Line 2
  Line 3
Credit Card Information
You will be charged $50 for this purchase.
* Name
As it appears on the credit card.
* Credit Card Type Visa     MasterCard     AMEX     Discover    
* Credit Card Number
* Expiration Date
MM/YY format
* Billing Address
As it appears on your credit card statement.