Donation: 2 Lines...........$50.00 -- 3 Lines...........$60.00

NAME : ________________________________________________________

ADDRESS: ______________________________________________________

CITY, STATE , ZIP CODE : ________________________________________

PHONE (DAY): ____________________ (NIGHT): ___________________

MESSAGE: (14 Character max per line)

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PAYMENT TYPE: __ CHECK __ MONEY ORDER __ MASTERCARD __ VISA

CREDIT CARD NUMBER ________-________-________-________

CREDIT CARD EXPIRATION DATE ____/____

SIGNATURE: __________________________________

MAIL TO : TALLADEGA-TEXACO WALK OF FAME
POST OFFICE DRAWER 1179 TALLADEGA, ALABAMA 35161

Please print the name or message you want engraved. You may use up to three lines and maximum of 14 characters per line, including spacing and punctuation. Please use only those letters or symbols that appear on a standard computer keyboard. Message and names will be centered and in all capital letters. Messages and names may not contain offensive or profane language, address public issues, support political opinions, promote or oppose religion or include a commercial or advertising message other than a company name. All messages and names will be subject to approval by Talladega - Texaco Walk of Fame.