BE A PART OF THE SALISBURY – ELK LICK VETERANS MEMORIAL!
A brick may be purchased for a veteran of all wars/conflicts by the veteran’s family or by the
general public. Each brick will have an inscription to honor the service or the memory of the
veteran. The paved bricks will an integral part of the memorial.
ORDER FORM

____ Memorial Brick $100.00
Name: _______________________________________________________________________
Mailing Address:
_____________________________________________________________________________
_____________________________________________________________________________
Phone Number:
________________________________________________________________
Message for Paved Memorial Brick (maximum of 3 lines; 20 characters or blank spaces per line
(18 characters preferred.)) * note: commas and periods count towards the 20 character
count.
Line 1 ________________________________________________________________________
Line 2 ________________________________________________________________________
Line 3 ________________________________________________________________________
Signature: _______________________________ (Your signature serves to verify that the
information to appear on brick is correct)

Make check payable to: The Salisbury – Elk Lick Veterans Memorial
Mail order form and check to: Veterans Memorial, P.O. Box 377, Salisbury, PA. 15558‐0377