Badlands Veterans Memorial

*First Name:

*Last Name:

Your Company:

*Street Address:

*City:

*State/Province:

*Zip code:

*Phone Number:

*Email Address:

*Clip Art/Logo/Artwork?: YES NO

*Brick/Tile Size: Select Brick/Tile4x8 brick(#7 BRONZE SPONSOR ) - $100.004x8 brick(RHS AFJROTC Booster) - $35.004x8 brick(SILVER SPONSOR) - $250.004x8 brick(GOLD SPONSOR) - $500.004x8 brick(PLATINUM SPONSOR) - $1000.00

*Amount($):