PlaqueRequestForm

			Prince of Peace $200.00 $500.00 $1000.00 Size 6 X 2



		St Theresa St Jude Our Lady of Guadeloupe $250.00 ea Size 2 X 4


MISC: Enter Amount Below


		$



	Size 6 X 2

	Hall of Fame $500.00 Size 2 X 8


	Veterans, Police, Rescue, Fire Fighters $250.00 Size 4 X 2.5

	Deceased Priest Chapel $250.00 Size 7.25 X 2.5

In the box below, enter exactly how the Plaque is to read.
Make certain all Spelling is Correct! Please Type or Print Legibly!
Three (3) Lines Max *** 30 Characters Per Line Max

Line 1 (30 letters Max)
Line 2 (30 letters Max)
Line 3 (30 letters Max)

Your Name

Phone #

Your Address:

Check #

Cash

Amount Paid $

Your Signature:__________________________ Proof OK (INT): _____

Office Signature:_______________________________

Client:National Shrine Date:__________ Quantity:________
Vendor Name:_____________________________________

INSTRUCTIONS
Please Fill Out Form, Click "Print me" sign and mail with payment to the:

National Shrine of Our Lady of Lebanon
2759 North Lipkey Rd
North Jackson, Ohio 44451

(Phone # 330-538-3351)

Our Lady of Lebanon
Plaque Request

No __________