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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 4�x 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. |
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Purchaser |
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Name |
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Address |
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Home Phone |
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Work Phone |
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Cell Phone |
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Email |
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Engraving
All lines will be centered. Limit each line to maximum of 16 characters including spaces and punctuation. |
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Line 1 |
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Line 2 |
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Line 3 |
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Credit Card Information
You will be charged $50 for this purchase. |
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Name
As it appears on the credit card. |
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Credit Card Type |
Visa MasterCard AMEX Discover |
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Credit Card Number |
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Expiration Date
MM/YY format |
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Billing Address
As it appears on your credit card statement. |
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