St. Mary Roman Catholic Church 19 Cherry Tree Farm Road Middletown, NJ 07748 Commemorative Paver Order Form PLEASE PRINT ALL INFORMATION Contact Information: Name: Last: First: Phone day: Cell: Address: E-mail: Choice of Paver Size – check box [ ] 4 X 8 - $200 [ ] 8 X 8 - $350.00 Please indicate the desired message to be inscribed on your paver. (Please limit the message to 50 characters including spaces - please print legibly) Method of Payment: [ ] Check [ ] Cash Check #____________ Amount $____________* Questions? Please contact Bonnie Stahl at St. Mary Church 732-671-0071. Please make checks payable to: St. Mary Building Fund* Return payment and completed form to: St. Mary Building Fund St. Mary Church 19 Cherry Tree Farm Road Middletown, NJ 07748 *Thank you for your contribution, which is tax-deductible to the extent allowed by law. Keep a copy of this form as a receipt of your donation. The inscribed paver is in recognition of your generous financial donation. No goods or services were provided in exchange for your donation.