VETERANS’ WALL BRICK ORDER FORM
Please print the information exactly as you want it on your brick. Leave a space between
words. Use a maximum of 15 spaces, but contact us if you need additional space.
Engraving is $65 per brick.
1st line: Name of armed forces member
2nd line: Branch of service (Army, Navy, Air Force, Marines, National Guard, etc.)
3rd line: Dates of military service (Example: 1942 – 1945)
Was this service member killed in action? Circle one: Yes No
Was this service member a POW? Circle one: Yes No
Contact person: _________________________________
Phone number of contact person: ______________________
Address of contact person: _____________________________________________________
Please make checks payable to Springlake-Earth National Honor Society
Please return this form and payment to S-E National Honor Society, PO Box 130, Earth TX 79031