-HONOR YOUR HERITAGE-

A FITTING TRIBUTE TO THE COAL MINERS OF

SCHUYLKILL COUNTY

ORDER YOUR BRICK TODAY

Make your contribution now to help support the effort to maintain the grounds surrounding the COAL MINERS STATUE at the intersection of Routes 209 and 901 in Schuylkill County.

Please indicate the number of memorials you wish to purchase, print the name(s) to be engraved on the bricks in the space below, and mail the form with your payment to:

MINERSVILLE ROTARY CLUB

P.O. BOX 813

MINERSVILLE, PA 17954

PRINT OUT FORM BELOW

I would like to purchase the following personalized brick memorial(s): _____ $200.00 Contributors 8" X8" Brick to be installed in walkway around statue 4 lines, 15 letters per line, including spaces _____ $100.00 Contributors 4" X8" Brick to be installed in walkway around statue 2 lines, 15 letters per line, including spaces (Please print clearly, using CAPITAL letters,the names or dedication you want imprinted thereon) 4" X 8"- 2 LINES-15 Characters per line, including spaces ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 8" X 8"- 2 LINES-15 Characters per line, including spaces ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ORDERED BY: Name:__________________________________________________ Address:_________________________________________________ City:____________________________________________________ State:______________________Zip Code:_____________________ Phone:_____________________________________ Checks should be made payable to: MINERSVILLE ROTARY CHARITIES, INC.

Minersville Rotary Club reserves the right to refuse/reject inappropriate wording that could be offensive.

For additional information or questions, E-mail James W. Quandel, Jr.