Order Form for Honor & Memorial Tiles

After you complete, print, and mail in the following online order form, you can pay with a credit card through Google Checkout below this form.

 

* Purchaser's Name:          * Required fields
* Address:  
* City:  
* State:  
* Zip Code:  
* Daytime Telephone:  
* Email Address:  
* Tile:  
* Indicate Tile Size:  
   
Create Your Own Tile - Please complete the applicable fields below with the letters as you would like to see on your tiles. Leave a space between names and before and after "&". There is limited space for each field. (You must complete at least line 1 of your chosen category.)
   
$250 Tile:    
Line 1   (maximum characters = 20)
Line 2   (maximum characters = 20)
   
$500 Tile:    
Line 1   (maximum characters = 20)
Line 2   (maximum characters = 20)
Line 3   (maximum characters = 20)
   
$750 Tile:    
Line 1   (maximum characters = 20)
Line 2   (maximum characters = 20)
Line 3   (maximum characters = 20)
Line 4   (maximum characters = 20)
   
$1,000 Tile:    
Line 1   (maximum characters = 21)
Line 2   (maximum characters = 21)
Line 3   (maximum characters = 21)
Line 4   (maximum characters = 21)
   
$5,000 Tile:    
Line 1   (maximum characters = 21)
Line 2   (maximum characters = 21)
Line 3   (maximum characters = 21)
Line 4   (maximum characters = 21)
Line 5   (maximum characters = 21)
   
$10,000 Tile:   (includes enrollment as a Club 200 member)
Line 1   (maximum characters = 21)
Line 2   (maximum characters = 21)
Line 3   (maximum characters = 21)
Line 4   (maximum characters = 21)
Line 5   (maximum characters = 21)
   
Comments:  
   
  Please print out this form and mail it to:
Czech Center Museum Houston
4920 San Jacinto at Wichita
Houston, Texas 77004

 


 

Pay with Credit Card:

 

Please choose your tile choice from the drop-down box and click on the Google Checkout Donate
button. Thank you.

 

Type of Tile