Create a memorial or tribute
in the Immaculate Conception Candle Shrine

You may complete this form online or download a printable form to mail.

Memorial/Tribute Information

*Please select a plaque size
4" x 16" plaque - 4 lines; 32 characters or spaces per line ($500)
8" x 8" plaque - 6 lines; 18 characters or spaces per line ($500)
8" x 16" plaque - 6 lines; 32 characters or spaces per line ($1,000)

*Line(s) to be etched:






Total: $

Credit Card Information

*Card Number:

*Expiration Date
/

*Security Code

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Billing Information

Title

*First Name

*Last Name

Suffix

*Address

*City/Town

*State/Province

*Zip/Postal Code
-

*Country

*Email

*Phone