(Press The Print Button On Your Browser For A Hard Copy Of This Form)
Send this completed form with payment to:
PCVMPC
c/o Canton Community Foundation
50430 School House Road Suite 200
Canton, MI, 48187

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In order for us to verify your inscription, please complete all information
(including your phone number!)Please Print Information!
First Name: ______________________________________  Last Name: ______________________    
Address: _________________________________________  Telephone: (Days)  (___) ________
   City: _________________ State:_____ Zip:_______  Telephone: (Nights)(___) ________
 E-Mail Address: _________________________________  Cellphone:         (___) ________
PAYMENT - Indicate paver selection below: Click: Read about the Park's Paver Program
__ 4" x 8" paver	quantity ordered ____	at $100 = $ __________
__ 8" x 8" paver	quantity ordered ____	at $250 = $ __________
__ Cash or Money Order
__ Check (please make payable to CANTON COMMUNITY FOUNDATION and write Plymouth
Veterans' Park on memo line)
__ Credit Card:		__ Visa	    __ Mastercard
Account # ____________________________ Exp. Date ____________
Cardholder Signature ____________________________ and Print Name ______________________
Billing Address of Cardholder _________________________________________________________ 
GIFTS - If you wish to purchase a paver as a gift in memory or in honor of an 
individual, gift acknowledgements are available for you to send to the recipient. 
Please indicate below the number of cards you would like (no more than 2 please).
__ Acknowledgement Cards #_____
VETERANS' PLAZA (GRAY PAVERS)- ONLY FOR VETERANS; inscriptions on forms do not need to be centered.
4" X 8" inscription area - maximun  of three (3) lines with 14 spaces per line:
PATHWAYS (RED PAVERS) - inscriptions on forms do not need to be centered.
4" X 8" inscription area - maximun  of three (3) lines with 14 spaces per line:
8" X 8" inscription area - maximun of five (5) lines with 14 spaces per line:
CASH DONATION - If you wish to just send a cash donation and not purchase a
paver, send your contribution to the address above!
THIS FORM PRINTED OFF THE PCVMPC WEBSITE: http://www.plymouth.lib.mi.us/~pcvmpc/