O R D E R   F O R M
 
The Walkway of Recognition
 
❑ YES, I want to order _______ concrete brick/s at $250.00 each.
(Please copy form for additional inscriptions).
 
Please Print Inscription
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The concrete bricks are 4x8 and can be engraved with up to 14 characters per line, three lines available, spaces and punctuation count as one character. Please find enclosed my check for $_________ for _________ bricks.

PLEASE PRINT:
Please charge my ❑ Master Card ❑ Visa
CARD #________________________ EXP. DATE_________
AUTHORIZED SIGNATURE____________________________
NAME___________________________________________
ADDRESS________________________________________
CITY________________________ STATE____ ZIP_______
PHONE (W)________________ (H)___________________

Send to Florida Pharmacy
Foundation, 610 N. Adams St.,
Tallahassee, FL 32301,
or fax to (850) 561-6758.

Contributions to the Florida Pharmacy Foundation are tax deductible as a charitable contribution for federal income tax purposes. Consult your CPA for complete details. Fed Emp. I.D. #59-2190074

A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE 1-800-435-7352 WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL OR RECOMMENDATION BY THE STATE.