Columbia Heights United Methodist Church Brick Paver Order Form

775 Galloway Road

Please print your information for one paver brick on this form and attach additional forms as needed for additional pavers. You may have up to three lines of inscription with up to thirteen (13) characters or spaces per line but only a total of thirty-nine (39) characters or spaces per brick. Bricks are $50.00 each and must be paid when you turn in your subscription.   One of the seven symbols represented below (actual symbols may look different) can be added to your brick for an additional $5.00.  Remember that the symbol will take up four to six spaces on the paver so plan your lettering accordingly.

Name:

Address:

Phone Number:

The Seven Christian Symbols Represented Below Are Available To Choose From

Cross

Butterfly

Descending or Ascending Dove

Fish

Methodist Flame

Two Rings

Heart

as of 08/15/2007