Wall of Tribute Order Form

***Please note: we cannot accept orders online at this time;
you will need to print the filled-out form and mail it to the address below.

Yes! I want to honor someone who has made a difference in my life and/or the lives of those in the field of blindness by including them in the Wall of Tribute.

Name:
Address:
City:           State:      Zip:

My check is enclosed*
*Make checks payable to Hall of Fame: Leaders and Legends

Please charge my credit card:
   Visa®
   MasterCard®
   Discover®

Card Number:   Exp. Date:
Signature:

Please select your tribute stone from the following list and write your inscription in the space provided. Each character (letter, space, or punctuation) takes up one of the available "characters per line."

	3 inch by 8 inch stone (2 lines, 15 characters per line) $375.00 (option: $125.00 for 3 years)
	4 inch by 8 inch stone (3 lines, 15 characters per line) $550.00 (option: $184.00 for 3 years)
	6 inch by 8 inch stone (5 lines, 15 characters per line) $1,000.00 (option: $334.00 for 3 years)
	8 inch by 8 inch stone (7 lines, 15 characters per line) $2,500.00 (option: $834.00 for 3 years) Can display a logo; call 502-899-2351 for details
	12 inch by 8 inch stone (11 lines, 15 characters per line) $5,000.00 (option: $1,667.00 for 3 years) Can display a logo; call 502-899-2351 for details
	Personal presentation stone (a beautiful replica of your Tribute stone, with stand) $75.00

Use the "Print Form" button or your browser's "Print" function to print this form. Mail the printed form to the address below.

Hall of Fame, c/o
American Printing House for the Blind, Inc.
1839 Frankfort Ave.
Louisville, KY 40206

Phone: 502-895-2405
Fax: 502-899-2363
Email: fame@aph.org
Web site: www.aph.org

Hall of Fame: Leaders and Legends of the Blindness Field is a project of the entire field of blindness. It is curated by the American Printing House for the Blind, a 501(c)(3) tax exempt organization.

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