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2. Personalized Veterans Blue Star Memorial Brick Order Form

   Please complete this form to purchase a customized brick to be placed at the Blue Star Memorial at the Village of Palos Park.  There is a maximum of three lines with twenty characters allowed per line.  The cost to purchase a customized brick is $60/each.  Payments can be made to the Village of Palos Park.  Please call Lisa at 708-671-3705 for additional information or to submit your payment.

4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
15. Personalization Line 1
17. Personalization Line 2
19. Personalization Line 3
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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