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 1Line 2Line 3Paver InscriptionLine 1Line 2Line 3Line 4Line 5Line 6Line 7Line 8Line 9Payment InformationTotal $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name
