Please use this form to order your commemorative brick(s) to be placed around the base of the Noel Neill Statue
in Metropolis, Illinois.
Print and mail the completed order form to:
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Noel Neill Statue Commemorative Brick
c/o The Metropolis Chamber of Commerce
607 Market Street,
Metropolis, IL 62960
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If you have any questions, please contact the Metropolis Chamber of Commerce at (618) 524-2714.
Name:________________________________________________________________
Company/Organization:________________________________________________
Address:_____________________________________________________________
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City:_____________________Province/State:_________Postal Code:_______
Daytime Telephone Number: (_______)__________________________________
Facsimile Number: (_______)__________________________________
E-Mail Address:______________________________________________________
Brick
Quantity ($75.00 Each)
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Brick
Inscription(s)
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Total Price ______________
PRICE IS FOR BRICKS ONLY - MEMORIAL PLAQUES MUST BE ORDERED SEPERATELY
Make checks payable to "The Metropolis Chamber of Commerce"
RECEIPT INSTRUCTIONS:
(Please indicate shipping address for your receipt to be mailed)
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