Version 3.0
Engraved Paver Order Form
Please join the Town of Lovettsville to make the Lovettsville Veterans Memorial a reality.
Recipient does not need to be from Lovettsville -- you may honor any family member or friend who has served
or is currently serving in United States Army, Navy, Marine Corps, Air Force, or Coast Guard.
Please help build a fitting tribute to veterans by purchasing an engraved paver at a cost of only $250.00 each.
In the spaces provided below, please print the information you would like on your 6x9 inch paver using the
examples shown (maximum of 3 lines and 20 characters, spaces and/or symbols per line). There is no limit to
the number of pavers you can order, but please use a separate form for each paver. Please print in BLOCK
letters - one letter or space per square.
Examples: 1) John Smith 2) PFC John Smith 3) PFC John Smith
U.S. Army World War II U.S. Marine Corps
1943-1957 1943-1957 World War II
The Town of Lovettsville has the right to deny any inscriptions that are deemed inappropriate. Due to the
architectural design, the actual location of individual pavers may not be specified nor guaranteed. Every effort
will be made to inscribe the pavers as they appear on your order form; however, modifications may be made to
insure inscriptions are compatible to paver size.
You will be sent a proof at a later date for your signature.
Sponsor's Name __________________________________________ Phone #_____________________
Address_________________________________________ City/State/Zip_____________________________
Email ___________________________________________________________________________________
Payment must accompany your order. Please make your check payable to the Town of Lovettsville and submit
Town of Lovettsville or use the afterhours drop box at the Town Hall
P.O. Box 209
Lovettsville, VA 20180
Price of paver: $250.00 Check # ______________ Credit card payments cannot be accepted
Thank you for supporting this important project.