Brick Application

Deterrent Park

Brick Application ($40/Brick Donation)

Type in Data, Print Out Form, Sign, Date and Send in with Check or Money Order to:

United States Submarine Veterans

Bremerton Base

PO Box 465

Silverdale WA 98383-0465

(Push PRINT icon on browser when form complete)

Rev:11/20/2010

NAME

STREET ADDRESS:
CITY: STATE:    ZIP:
PHONE: E-MAIL:

COMMENTS:

Enter your inscriptions below; Up to 15 characters and/or spaces per line. Each brick will be engraved with capital letters, and each line will be automatically centered.

1ST BRICK

        Line #1              Example:   JOHN PAUL JONES

        Line #2                                  FATHER OF THE

        Line #3                                 AMERICAN NAVY

2ND BRICK

        Line #1              Example:   IN MEMORY OF

        Line #2                                     JOHN DOE

        Line #3                                      CDMC(SS)

Please make check or money order payable to: "USSVI Bremerton Base"
MAIL TO: United States Submarine Veterans, Bremerton Base, PO Box 465, Silverdale WA 98383-0465

Signature____________________________________________Date_________________________
(Push PRINT icon on browser when form complete)

Deterrent Park Gertrude Check

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