DONATION AND INCLUSION FORM

Please fill out this form, print and mail to: Western Slope Vietnam War Memorial Park:
P. O. Box 340 Fruita Colorado 81521

Below are four ways you can include yourself or a loved one in the Western Slope Vietnam War Memorial and make a donation towards this lasting tribute to those who served. Please choose one or more of the following

Personalized Etching Vietnam Era Veterans Wall a $100 Donation
 Personalized Etching, Vietnam Era Veterans Wall..KAI..MIA..POW
(Donated without charge in honor of their sacrifice)

Name as it should appear on the granite wall

Walk of Honor Imprinted Bricks a $75.00 Donation
Name as it should appear on your Walk of Honor Brick

Corporate or Business Sponsor $1000 $5000 $10,000

HONOREE INFORMATION

BRANCH OF SERVICE Army Navy Air Force Marines Coast Guard

Dates of Service: From To

Military Identification Number

NAME
ADDRESS1
ADDRESS2
CITY STATE ZIP
PHONE E-MAIL

This is a Tax Deductible Contribution, by filling out the above application, you are giving
Western Slope Vietnam War Memorial Inc. permission to verify military service and dates for
inclusion on the granite Vietnam Era Veterans Wall.

Signature__________________________________ Date_______________

Any questions contact Jim Doody: 970-242-0073 e-mail doody@gj.net