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CLASS OF 1961 DONATION FORM
for a 12” x 12” Engraved Paver
from our Class Website: www.classinfo1961.com
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(I/we ) __________________________ would like to contribute to the Class of 1961 “Legacy Paver”
to be placed in the River Front walk way for a historical attribute representing our class.
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Tax deductible donation of: $_________.
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Date: ________
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Check No.: _________
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Name: ______________________________
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Address: ___________________________________
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_________________________________
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Phone No. ____ x ____ x _______
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E-mail :__________________________________
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(Make check payable to: Kay Miller) and mail to:
Kay Miller 115 So. Hennepin Ave. Dixon, IL 61021
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