Request for Memorial Brick

NAME _______________________________________ Telephone _____________________

Address _____________________________________________________________________

How to invest in the Future of the Library

Please return this form with your $100 tax deductible donation to:

Eccles-Lesher Memorial Library
P.O. Box 359
Rimersburg, PA  16248


Write your Commemorative Brick inscription in the boxes below:

Limit 3 lines with 13 characters per line. Print in capital letters, only 1 character per space.
All requests are subject to approval by the Library Board of Directors.