Fallen Firefighter Memorial

Brick Order Form

$100.00 Per Brick

Complete Order Form And Return With Check or Money Order

Make Payable To:

Milwaukee Fire Historical Society, Ltd.
711 West Wells Street
Milwaukee, WI 53233
Attention: Jim Ley

                    Name: __________________________________________________________

                   Address: ________________________________________________________

                  City/State/Zip:____________________________________________________

                  Phone Number/E-mail Adress:______________________________________
 

In the boxes below please print the name you would like on your brick, the number of boxes shown
is the maximum amount of letters per line per brick. (12 characters per line-spaces and hyphens count)

Thank You for Your Order