EMMR "One Block At A Time" Order Form
Yes! I want to be a part of the excitement of the Eastern
Museum of Motor Racing by purchasing
______ block(s) @ $550 each.
I would like the inscription to say: (1 character per space)
| ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ |
| ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ |
| ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ | ______ |
(Maximum of three lines, 14 characters per line, including spaces and punctuation.)
Block Location: 1st choice:
______ 2nd choice: ______ 3rd choice: ______
Date:
____________
Daytime Telephone Number: (____) _____-________
Name: ________________________________
E-mail: __________________________
Address: _________________________________________________________________
City, State, Zip Code: _______________________________________________________
Enclosed is my check for (total amount) $____________ Please make payable
to EMMR
Visa or Master
Card:
Card #: ________ ________ ________ ________
Expiration Date: __________ Your Signature:
__________________________________
Mail to:
Eastern Museum of Motor Racing
"One Block at a Time"
c/o Joe Heisler III
27 Cottage Avenue
Glen Rock, PA 17327
For more information, contact Joe Heisler III (410) 290-1018, or jlh3@erols.com
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