Commemorative
Opportunity
Application

Yes, I would like to be a part of history and order _______ bricks at $75.00 each

(Please fill out and include 1 sheet for each brick you are purchasing)

Total Enclosed $ ___________

Your Name:	___________________________________
Address:	___________________________________
	___________________________________
Daytime/Phone:	_____-______-_____________

Place an X next to the dedication you want.  Write out your memorial message in the boxes below.  Make sure you have 1 letter in each box.  Please include spaces between words.  Limit 36 characters.

Dedication (Select One)

___ In Memory

___ In Honor

___ Blank

*Make Checks Payable to Beaver Borough and Send to:

Beaver Borough, 469 Third Street Beaver, PA. 15009