Northern Rockies Heritage Center
At Historic Fort Missoula

Exterior TREE PLAQUE, Coated Brass:

4" x 6" ($300)_____

8" x 10" ($500)_____

Interior FOYER PLAQUE, Brass:

3" x 5" ($150)_____

4" x 6" ($250)_____

PLAQUE TEXT REQUESTED
(applicant please clearly print or type text with line breaks below):

1. text here________________________________________________________
2. text here________________________________________________________
3. text here________________________________________________________
4. text here________________________________________________________

CAMPUS LOCATION DETERMINED:___________________________________________________

DETAILS/VARIANT TERMS:________________________________________________________

__________________________________________________________________________________

APPLICANT SPECIAL INSTRUCTIONS:_______________________________________________

__________________________________________________________________________________

APPLICANT NOTE: Please complete & return this form, with check payable to N.R.H.C.
Mail to: N.R.H.C., #30 Fort Missoula Rd., Missoula, MT 59804

PLEASE CHECK HERE______ if you wish a copy of this form returned to you for IRS Charitable Tax Deduction 501(c)(3) documentation.

PLEASE CHECK HERE______ and add $10 if you wish to receive a printed facsimile of your plaque, suitable for framing.

Northern Rockies Heritage Center · Tree Memorials · nrhc form CM 1A September 2003

©2004 Northern Rockies Heritage Center · Site by webscribe