Back
For Donations  please "PRINT" this form, fill it in and mail it with your payment in the form of  a Personal Check,
Money Order, or Credit card to:
                                                            The Stars and Stripes Museum/Library Association, Inc.®
                                                            17377 Stars and Stripes Way
                                                            P.O. Box 1861                             
                                                            Bloomfield, Missouri 63825 
Name:____________________________________________________________

Street:____________________________City:____________________________

State:_____________________Zip:___________Phone: (       )_____________

Signature:_________________________________________________________

Price: $50.00 Per Brick. 
Visa and MasterCard also accepted. Please check one.

 h_logobug.gif (516 bytes)         mc100.gif (1653 bytes)

Credit Card #:___________________________Expiration Date:____________

Signature:________________________________________________________

Member                                     $25.00

Business/Organization                 $100.00

Commemorative Brick*              $50.00

Other Donation                         $_______

Make checks payable to:
                   The Stars & Stripes Museum/Library Association, Inc.®
Fill in the blocks below as you wish your choice of name to appear. Blocks can be up to 14 characters per line, with a maximum of 3 lines.  Lines and characters will be centered if less than 3 lines desired.

block.jpg (20601 bytes)
The Stars and Stripes Museum/Library Association® is Incorporated under General Not For Profit Corporation Laws.  All donations are tax deductible under Section 501 (C)(3) of The Internal Revenue Code.