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Prowers Medical Center

Engraved Bricks

NOTE: Logos are available at additional cost and decreases the available inscription space. Please contact the Foundation Office for more information.
Only one brick can be ordered per order form.
You may also contact the Foundation office at 719-336-7065
* Donor's Name
* Address
* City
* State
* Zip
* Telephone
  I would like to purchase the following $150 4" x 8" Engraved Brick
$200 8" x 8" Engraved Brick
$25 1-1/2" x 3" x 5/8" Mini Engraved Brick
Information to be engraved
4x8 Bricks - Maximum of 3 lines with up to 20 characters per line, spaces and punctuation are considered characters. 8x8 Bricks - Maximum of 6 lines with up to 20 characters per line, spaces and punctuation are considered characters. PLEASE PRINT CLEARLY
  Line 1
  Line 2
  Line 3
Lines 4 - 6
(lines 4-6 are available in addition to 1-3 on 8x8 bricks only)
  Line 4
  Line 5
  Line 6
Please send acknowledgement of my gift to:
  Name
  Address
  City
  State
  Zip
  Amount of your payment
Please Specify How Much You Are Paying. Please Use Dollars and Cents.
  Credit/Debit Card Type
Select Credit/Debit Card from the list.
Visa     Master Card     Discover    
  Credit/Debit Card Number
Input The 16 Digit Number Just As It Appears On Card
  Credit/Debit Card Expiration Date
mm/yy
  Credit/Debit Card Security Code
Please enter the last three digits from the security code on the back of your credit/debit card. We can not process your payment without this information.
For questions/additional information, please contact the Foundation office Monday through Friday 8:00 a.m. to 5:00 p.m. at 719-336-7065 or foundation@prowersmedical.com