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)’s 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 President’s 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

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Brick # 1

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

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

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

Brick # 2

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

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

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