Memorial Park – N-SSA Engraved Brick Memorial Request Form NAME
UNIT: Year Deceased or memorial notation (ex. From loving family)
Description of memorial bricks Bricks are 4” x 8” in size Laser Engraved
All bricks will be of the same font and color
Directions: Please print clearly on the form. Only deceased N-SSA members may have a brick placed in Memorial Park. Duplicate bricks may be ordered at the same price (Ex. One brick for Memorial Park, one brick for family, team, etc.). Please indicate this on the form. Duplicate brick(s) ordered can be picked up at the secretary’s office during each nationals. Duplicate bricks will not be shipped. Number of bricks ordered__________ @ $30.00 each Total Amount submitted $___________ Make Checks Payable to: North-South Skirmish Association Submitted by: Name: _____________________________________________ Unit Name:_______________________________________ Unit Number and Region ________ Contact number or email address___________________________________________________ Mail to: Executive Secretary Judy Stoneburner P.O. Box 218 Crozet, VA 22932-0218 ****************************************************************************** Office Use Only: Date Received: ____________________________ Check #________
Amount $___________
Brick Placement________
Deposit Date_____/_______/_____
Extra Brick:
NO
YES
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43 Skirmish Line Summer 2021
Auguest 2021.indd 44
8/16/2021 12:11:22 PM
