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.