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2. 

3. Halloween Witch Medallion Paver or Metal Medallion Fundraiser

   Order Form

5. Name
6. Email Address
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
16. 12 X 12 Paver
17. Qty @ $95 Donation
    -- Select One --12345
20. 8 X 8 Paver
21. Qty. @ $45 Donation
    -- Select One --123456
23. Metal Medallion
24. Painted/Unpainted
    -- Select One --Painted - $45 donationUnpainted - $40
26. 
    

    Pavers must be picked up at Anoka City Hall, 2015 First Ave. N,, Anoka, MN  55303

    Staff will contact you when your paver order is available for pick up. Only a limited number of pavers will be available. Depending on demand there may be a delay in the availability of paver. Thank you for your patience

    For questions please contact Clark Palmer at 763-576-2728

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29. Email address

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