J.I.M.'s Commons' Brick Order Form

 

 

I/We are Bereaved Parent(s) Name(s): ______________________________Other __________________

 

Mailing Address: ______________________________________________________________________

 

City: ___________________ State : _____ Zip: _________ Telephone: __________________

 

Child(ren)ís Name(s): _______________________________________________ Age(s):_____________

 

Birth Date(s) ________________________________ Death Date(s)______________________________

 

Cause of Death(s) ________________________________Symbol(s)_____________________________

 

E-mail Address_________________________ Website________________________________________

 

The price is $50.00 each.

 

Please PRINT order form (this cannot be completed through the website) and return with payment to:

Mrs. Dinah Taylor

804 Main Street

Williamsburg, KY 40769

Or, if you would like to pay with a credit card, please call the Presidentís Office at 606-539-4202 and tell them you would like to order a brick for J.I.M.'s Commons. Make all checks payable to University of the Cumberlands for J.I.M.'s Commons. The bricks measure 4 x 8 x 1 and will allow for 14 to 15 print spaces. Letters, commas, spaces, etc. are considered print spaces.

Example:

 

Jim Taylor, II

7/26/72 - 5/20/91

Pegasus

-

Brick # 1

 

Line 1 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 2 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 3 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

 

 

 

 

   

 

Brick # 2

Line 1 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 2 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 3 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___