Fill and Sign the Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement Form

8” x 8” GOWEN FIELD MEMORIAL BRICK ORDER/ CASH DONATION FORM Use this form to order a brick to commemorate your service member’s contribution to America’s defense. The brick will be placed among other veterans’ bricks in one of the Gowen Field Memorial Park sidewalks. One brick per order form please. You can also use this form to make a cash donation. 8” x 8” Bricks: (6 Lines of Text, each line of 19 Characters) $100.00 Your purchase/donation is totally tax deductable as a contribution to the Gowen Field Memorial Park Foundation Fund (a not for profit organization). Please make your check payable to the Gowen Field Memorial. Mail to: Gowen Field Memorial c/o Idaho Military Historical Society 4040 Guard Street Boise, Idaho 83705 Cash Donation $_______________ Your cancelled check is your receipt. Please print clearly using dark ink and characters/symbols found on a common keyboard. Please print only one character per block. Messages will be edited for appropriateness only. Name J O H N Rank, Branch Service Dates Message S G M U S J U N 1 9 6 5 - H I S L O V E A M E R I A F I T R S J C A I M E S A R M Y N S M I T 9 9 5 A L W A M A Y 1 F O R W A S H I S H E H A Y S R T Service Dates Example: MMM YYYY-MMM YYYY (DEC 1920-JAN 1945) My Personal Check is enclosed________ Total Cost $________ For questions regarding the commemorative bricks please call the Idaho Military Historical Society Museum at 208.272.4841. Your Contact Information: Name:_John J. Smith____________________ Address:________1234 Main Street, Hometown, ID 83000--------------------E-Mail:________jjs@gmail.com___ Phone (Optional): _208.555.1212