Falls Creek Brick/Paver Order Form Contact InformationName* First Last Church Name* Please include City: "Seminole, First" Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Which type of brick would you like to purchase?* Brick ($100) Paver ($250) Bricks are 4x8" and can have up to three lines of text with 16 characters per line. Pavers are 12x12" and can have up to 9 lines with 20 characters per line.Brick InscriptionLine 1 Line 2 Line 3 Paver InscriptionLine 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 Line 8 Line 9 Payment InformationTotal $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name
