Name ___________________________________________________

Address _________________________________________________

City/State/Zip ____________________________________________

Phone __________________________________________________

Each "Rock" can have up to 2 lines, with 14 characters per line, including spaces.  Place your message below as you desire it to appear on the Signature "Rock":

Line 1 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Line 2 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

To order more than one Signature "Rock", enclose a separate sheet with your name and message, and an additional $50 per Signature "Rock".

Print this form off, complete it, and mail with your payment (made out to C.D.A.) to:

Chimney Rock Village
Community Development Association
P.O. Box 11
Chimney Rock, NC 28720

Other RiverWalk memorial purchases are also available (benches, picnic tables, trees, etc.).  Please write for additional details.

Designed by Mark J. Brewer
Rocky Broad River Enterprises