Memorial Plaque Order Form - JRCCEastThornhill.org

Part 1 - Information of the person whose memory you wish to honor
(The information in this part is used to make the plaque; please complete exactly the way you would like it to appear. Click here to see a close up of the plaque)
Full Name

First Name (English & Hebrew) Last Name
Father's Name

First Name Last Name
Mother's Name

First Name Last Name
Date and Time of Passing

/ Month / Day Year at

: Hour Minutes
Part 2 - Relative information
(Information of the relative requesting plaque)
Full Name

First Name Last Name

Address

E-mail
Relationship to the person that passed away
Part 3 - Secure Payment information
Amount Due

$500 for regular size plaque. $1800 for triple size plaque on top row

Payment

Credit Card Put pledge on my account, I will pay by cash or check

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Part 1 - Information of the person whose memory you wish to honor