Legacy Tile Order From
In exchange for your support, a tile will be permanently installed and displayed in our reception room.
To show your support please fill the form below and submit with your donation.
Tile
Size
in
Inches
4 by 8
8 by 8
12 by 12
Size (circle one)
Donation
Number Characters
Level
$300 to $499
$500 to $999
$1000 or More
4 by 8inches/3 lines
of
Lines
3
6
9
8 by 8inches/6 lines
per Line
14
14
21
12 by12inches/21 lines
Line 1:______________________________________________________________________
Line 2: ______________________________________________________________________
Line 3: ______________________________________________________________________
Line 4: ______________________________________________________________________
Line 5: ______________________________________________________________________
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Line 6: ______________________________________________________________________
Line 7: ______________________________________________________________________
Line 8: ______________________________________________________________________
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Line 9: ______________________________________________________________________
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Donor’s Name:______________________________
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Donor’s Phone:________________
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Donor’s Address:_____________________________________________________________
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Donor’s Email:______________________________
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Thank you for supporting The Bartz-Altadonna Community Health Center!