|
Serenity
Walk
SERENITY
WALK
The Wellness Community
Reservation Form
NOTE: Please print this form
and mail with payment to:
The Wellness Community
Attn: Serenity Walk
4918 Cooper Road
Cincinnati, Ohio 45242
or fax the completed form to
513.791.8239
Your Name:
_______________________________________________
Address:
_________________________________________________
City: ___________________________
State: ______ Zip: ________
Signature:
________________________________________________
I don't wish to buy a brick, but
would like to donate to The Wellness
Community's Serenity Walk.
Enclosed is my check or credit card
payment in the amount of
$____________.
B R I C K I N S
C R I P T I O N I N F O R M A T I O N
Total number of bricks ordered
______ x $100.00 = $_____________
One, two, or three lines are
available. Up to 14 characters per line.
(Examples include: In memory of, In honor of, Name, Family Name,
etc.)
BRICK #1
LINE #1:
_______________________________________________
LINE #2:
_______________________________________________
LINE #3:
_______________________________________________
BRICK #2
LINE #1:
_______________________________________________
LINE #2:
_______________________________________________
LINE #3:
_______________________________________________
Payment must accompany this
form. Please make checks payable
to The Wellness
Community. We accept Visa, Master Card, and
American Express.
Please circle the type of card used.
Credit Card #:
___________________________________________
Expiration Date: _______
Name on card: ____________________
Signature:
______________________________________________
|
