ORDER FORM

PURCHASER’S NAME

STREET ADDRESS

CITY

STATE

ZIP

PHONE

INFORMATION TO BE ENGRAVED ON 4” X 8” PAVER
3 LINES OF UP TO 14 CHARACTERS PER LINE, PER PAVER,
SPACES AND PUNCTUATION
ARE CONSIDERED CHARACTERS, PLEASE PRINT CLEARLY.

PLEASE DO NOT ADD BOXES.

Please send the completed form along with your check for
$50.00 payable to GRAUE MILL AND MUSEUM to:

Graue Mill and Museum
3800 York Road
Oak Brook, IL 60523

If you choose to charge the $50.00 to your credit card,
please complete the information below and fax the form to
(630) 920-9721.

Charge $ to my [ ] VISA [ ] Mastercard

Account Number:

Expiration Date:

Signature (Required for credit card purchases):