Order Form for Honor & Memorial Tiles for Czech Center Museum Houston

Winner of the 2008 Eventective Planner's Choice Award

After you complete, print, and mail in the following online order form, you can pay with a credit card through Google Checkout below this form.

* Purchaser's Name:	* Required fields
* Address:
* City:
* State:
* Zip Code:
* Daytime Telephone:
* Email Address:
* Tile:
* Indicate Tile Size:

Create Your Own Tile - Please complete the applicable fields below with the letters as you would like to see on your tiles. Leave a space between names and before and after "&". There is limited space for each field. (You must complete at least line 1 of your chosen category.)

$250 Tile:
Line 1	(maximum characters = 20)
Line 2	(maximum characters = 20)

$500 Tile:
Line 1	(maximum characters = 20)
Line 2	(maximum characters = 20)
Line 3	(maximum characters = 20)

$750 Tile:
Line 1	(maximum characters = 20)
Line 2	(maximum characters = 20)
Line 3	(maximum characters = 20)
Line 4	(maximum characters = 20)

$1,000 Tile:
Line 1	(maximum characters = 21)
Line 2	(maximum characters = 21)
Line 3	(maximum characters = 21)
Line 4	(maximum characters = 21)

$5,000 Tile:
Line 1	(maximum characters = 21)
Line 2	(maximum characters = 21)
Line 3	(maximum characters = 21)
Line 4	(maximum characters = 21)
Line 5	(maximum characters = 21)

$10,000 Tile:	(includes enrollment as a Club 200 member)
Line 1	(maximum characters = 21)
Line 2	(maximum characters = 21)
Line 3	(maximum characters = 21)
Line 4	(maximum characters = 21)
Line 5	(maximum characters = 21)

Comments:

	Please print out this form and mail it to: Czech Center Museum Houston 4920 San Jacinto at Wichita Houston, Texas 77004

Pay with Credit Card:

Please choose your tile choice from the drop-down box and click on the Google Checkout Donate button. Thank you.