Order Form - Wing House Museum-Branch County Historical Society

Order Form - Wing House Museum-Branch County Historical Society

Be Part Of The
Wing House History
Branch County Historical Society 8” X 8” Engraved Brick Order Form
Donor Name:___________________________________________________________________________
Address:______________________________________________________________________________
City, State, Zip:_________________________________________________________________________
Telephone:___________________________________ Cell:____________________________________
e-Mail:____________________________________________
Please make checks payable to: Branch County Historical Society
27 South Jefferson Street, Coldwater, MI 49036
Questions: Please contact Lynnell Eash (269) 268-0280
Donation for each 8” X 8” brick is $100
Use one order form for each brick
Order accuracy depends on you. Please PRINT clearly and place only one character or
punctuation mark in each box. Leave boxes empty to indicate spaces between words.
Your inscription will be automatically centered on the brick.
Office Use Only: Donor Payment Information
Office Use Only: Order/Brick Number