Give a Gift of Life That Lasts for Decades

YES.  I'd like to show my support for the American Heart Association and honor the person or organization whose name is listed below. (Please use one order form per brick.)

CLEARLY PRINT the honoree's name with the first name first. Three lines are available with no more than 12 characters (letters and spaces) per line.

Please print this form and mail to the address below:

_______________________________________________________________________________
12 characters only

_______________________________________________________________________________
12 characters only

_______________________________________________________________________________
12 characters only

Your Name _____________________________________________________________________

Street Address _________________________________________________________________

City __________________________________     State ___________     ZIP ___________

Telephone Number ___________________________________________

Amount enclosed ($120 per brick) $______________.
Make check payable to the American Heart Association


Charge to     ______ VISA     ______ MC     ______ American Express
(please check one)

Account Number _________________________________________________________

Expiration Date ____________________________________

Name on Account ____________________________________________________________

Signature ___________________________________________________________

__________ Please send me an acknowledgement that I can send to the person I am honoring.

__________ Please send an acknowledgement on my behalf to:

Name ___________________________________________________________

Street Address _______________________________________________________

City __________________________________     State ___________     ZIP ___________

Please indicate how you wish to sign the acknowledgement card

_______________________________________________________________________________

Print and complete this form and send it with your payment to:

Heritage Brick Walk
American Heart Association
P.O. Box 841750
Dallas, Texas 75284-1750

For security purposes, donations are sent to a bank lockbox before being delivered to the American Heart Association National Center, Office of Field Operations.  Donations and brick purchases are acknowledged  upon receipt in the Office of Field Operations. Depending upon the timing of your brick order, it can take several months for the brick to be engraved, delivered and installed.

Thank you for your support!