The City of Wellston, Ohio
RECREATION DEPARTMENT
Memorial Brick Order Form

Please print this application on your computer, then fill it out and mail to:

Wellston Recreation Department
City Building
203 E Broadway St
Wellston, OH 45692-1521

Small Bricks (4" by 8") are $40
Large Bricks (8" by 8") are $60
Enclose a check, payable to Wellston Recreation Department, for the appropriate amount.

The small bricks will be used to create a walkway to our new Football/Soccer
Stadium complex. Large bricks will create a Memorial Wall at the stadium entrance.


Your Name________________________________________________________

Address__________________________________________________________

City____________________________________ State________ Zip__________

Home Phone_________________________ Cell Phone_____________________

E-mail address_____________________________________________________


Please complete the bottom of this page to show us how your business
or personal name should appear on the Memorial Brick.

Two lines of letter space are available at 30 characters (including spaces) per line.


FIRST LINE_____________________________________________________________


SECOND LINE___________________________________________________________


Thank You!
Questions? Call Scot Sturgill at (740) 418-8632.

Form R5
WRD-05/rbc