Engrave a name on the Wall for the Ages

I hereby print (or type) the name, spelled exactly as I commission the World Commemorative Center, a division of Center of the World, Inc., to engrave it in granite on:


_____	THE WALL FOR THE AGESŽ ($75 for each name)

_____	The Millennium Wall (tm) section of THE WALL FOR THE AGESŽ ($100 for each name)

print or type name in box

Price includes 20 letters; Please add $1.00 for each additional letter.

and approve the above. I understand that engraving may take twelve or more weeks.

Signature:______________________________ Date:_______________

If we have questions, how may we reach you?

Name: ________________________________________

Address: ______________________________________

City: ___________________ State: _______________ Zip: __________

Telephone: _____________________________________

Fax: __________________________________________

E-mail: ________________________________________

PAYMENT

_____

I am enclosing a check or money order, payable to the WORLD COMMEMORATIVE CENTER

_____

Please charge the amount, ___________________, to the credit card indicated below:

_____Mastercard _____Visa

Card Number: _________________________

Expiration Date: _______________

Accountholder's Name: _____________________________________

Address to which monthly statements are delivered:

Street/PO:_________________________________________________

City, State, Zip: _____________________________________________

Telephone Number: _________________________

Authorized Signature: ____________________________________________