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2. Brick Order Form

4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Email Address*
17. Type of Brick
    -- Select One --Veterans -$75 Friends of the Village -$110Business Friends of Village -$525
18. Service Branch
    -- Select One --ArmyNavyAir ForceMarinesCoast Guard

20. Veterans Brick:4 lines of text with 16 characters per line

    Friends of the Village Brick: 6 lines of text with 13 characters per line

    Business Friends of the Village Brick 8x8: 6 lines of text with 13 characters per line

    The Village reserves the right to approve the wording on the bricks.

22. Please share the text you would like displayed on the brick, depending on the type of brick you have chosen above
24. Other sponsorship opportunities
    -- Select One --Service Branch Medallions -$500Benches -$2000Service Flagpole -$3500US Flagpole -$4000

26. If paying by check, please make check payable to the Village of Hanover Park and mail completed form and payment to: 

    Village of Hanover Park 

    Public Works Department 

    Attn: Veterans Committee

     2041 Lake Street Hanover Park, IL 60133

     If paying by credit card, MasterCard and Visa will be accepted, but you will have to visit Village Hall to make your purchase.
    

    This purchase is tax deductible

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field