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2. Veteran's Last Name*
4. Veteran's First Name, Middle Initial, Suffix:*
6. Please note that there is a limit of 15 characters per line, including spaces. There is a 4 line maximum per brick. Nicknames may be accommodated.
8. Branch of Service (check one):*

   1. Air Force
   2. Army
   3. Coast Guard
   4. Marine Corps
   5. Navy
   6. Other (You will be contacted for info)
10. Conflict (optional): check all that apply

    1. Afghanistan
    2. Gulf War
    3. Iraq
    4. Korea
    5. Vietnam
    6. WW I
    7. WW II
    8. Other (You will be contacted for info)
12. As well as the brick at Veterans Memorial Plaza, you will be included in the Veterans Kiosk which allows visitors to the Plaza to search for bricks and can include more of your service story. This information is optional.
14. What are your years of service? (ex. 1945-1952)
15. Where were you born?
17. Would you like to upload a photo?
18. You may submit a second photo here.
20. Would you like to include a brief biography of your time in the Service?
22. Would you like to be contacted for a Veterans History Project interview?

    1. Yes
    2. No
24. Contact Name:*
26. Address:*
28. City:*
29. State:*
30. Zip Code:*
32. Daytime Phone:*
33. E-mail:
35. Bricks for Veterans is happy to accept cash, checks, Mastercard or Visa at the Burleson Recreation Center, 550 NW Summercrest Blvd. Burleson, TX 76028. Bricks are $25.00 each.
37. You will be notified when your brick is placed at Veterans Memorial Plaza. If you have any questions or comments, please contact the us at 817-426-9104 or veterans@burlesontx.com.
39. Burleson Bricks for Veterans began in 2007 with the vision of a dedicated citizen, Betty Shelton and two Burleson businessmen, Rocky Bransom and Jim Garrett. The memorial began as a fountain with room for 200 bricks inlaid in the sidewalk. That number quickly increased to 900, then 1,200.
41. The Veterans Park was renovated in 2014 and rededicated as Veterans Memorial Plaza. The new plaza can accommodate 3,024 Veteran bricks. Veterans Memorial Plaza is at the corner of Renfro Street and Interstate 35. The bricks include the name of the Veteran, branch of service, and the name of any conflict in which the Veteran served. Bricks are for Veterans with a Burleson connection.
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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

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