Wytheville Walk of Fame Brick Program

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Purchase an engraved brick for yourself, your business, a loved one, or in a special memory. Your brick purchase not only memorializes the name or business listed, it also provides essential support to the Edith Bolling Wilson Birthplace Museum! You can contact the museum with questions or to request a paper form by calling (276) 223-3484 or emailing info@edithbollingwilson.org.

Price Options *

Mail a check - make payable to Edith Bolling Wilson Birthplace Museum, 145 E Main Street, Wytheville, VA 24382

Pay online - click the "Pay Online" button at the bottom of this form

Other:

Contact Information

Please provide complete contact information so we can ensure that your brick order looks exactly as you want it.

First & Last Name *

For Corporate Bricks: Business Name (we will contact you for additional information) *

Best Contact Phone *

Best Email *

Mailing Address *

Choose your contribution level: select the size or contribution level you would like. Then, find the corresponding box below and enter the text you want engraved on the brick as directed. *

$175 4x8 Brick Paver

$500 8x8 Brick Paver

$1,000 Corporate Sponsorship Paver

$175 - 4x8 brick paver - 3 lines of text, up to 13 characters per line including spaces

$500 - 8x8 brick paver - 5 lines of text, up to 13 characters per line including spaces

$1,000 - Corporate Sponsorship Brick with business name and logo ( a representative will contact you for details)

Do you want your recipient to receive a certificate announcing your gift? See sample certificate below. *

Yes

If yes, please complete the certificate personalization and contact information below. If no, you may skip to the payment button at the bottom of the page.

Who is the gift for? Name of recipient as you would like it to appear on the certificate. (Example: Mary, Mr. Thompson, etc.)

Who is the gift from? Name of giver as you would like it to appear on the certificate. (Ex. Bob, Your Favorite Kid, etc.)

Do you want the certificate mailed (hard copy) or emailed (electronic copy)? You may choose both.

Mailed - Hard Copy

Emailed - Electronic Copy

Do you have a specific date by which the recipient should receive the certificate? (Examples: holidays, birthday, anniversary, etc.) If yes, please list the date. Please allow 7 business days for a hard copy certificate to be processed and mailed.

YYYY

Enter the contact information as indicated above so we can send the certificate (email, mailing address, or both.)

Thank you!

You will receive confirmation as soon as we receive both this form and your payment. Please call (276) 223-3484 or email info@edithbollingwilson.org with any questions

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Edith Bolling Wilson Birthplace Foundation & Museum.