1. AFD MEMORIAL BRICK SPONSORSHIP FORM  PLEASE PRINT CLEARLY AND PUT ONE LETTER IN EACH BOX. ALSO SPACES COUNT AS A CHARACTER, SO PLEASE LEAVE A BOX BLANK BETWEEN WORDS  Please check here if you would like to sponsor a memorial brick in the honor of a departed AFD member. NAME: _________________________________ ADDRESS: _________________________________ _________________________________ PHONE: _________________________________ Please send form and check Payable to: AFD Memorial Fund 55 West Oak Street Amityville, NY 11701 Amount enclosed: Brick:$ 200.00 Departed Member Brick: $ 75.00 In lieu of a brick, please accept a donation in the amount of: __________ Total enclosed: __________

2. DEPARTED MEMBER BRICK SPONSORSHIP FORM NAME: _________________________________ ADDRESS: _________________________________ _________________________________ PHONE: _________________________________ Please send form and check Payable to: AFD Memorial Fund 55 West Oak Street Amityville, NY 11701 Amount enclosed: Brick:$ 100 In lieu of a brick, please accept a donation in the amount of: __________ Total enclosed: __________ Please note there will be only one brick for each member (Please put a single letter in each box, Line 1 First Name, Line 2 Last Name)  LINE 3: Place a check mark in the appropriate box Rank: (if applicable)  Ex-Chief  Ex-Captain Company: (Please select only one Company)  Hose Co. 1  Hose Co. 2  Hose Co. 3  Hose Co. 4  H & L Co. 1  Fire Police  Ladies Auxiliary

3. AFD MEMORIAL CORPORATE BRICK SPONSORSHIP FORM  PLEASE PRINT CLEARLY AND PUT ONE LETTER IN EACH BOX. ALSO SPACES COUNT AS A CHARACTER, SO PLEASE LEAVE A BOX BLANK BETWEEN WORDS  Please check here if you would like to sponsor a memorial brick in the honor of a departed AFD member. NAME: _________________________________ ADDRESS: _________________________________ _________________________________ PHONE: _________________________________ Please send form and check Payable to: AFD Memorial Fund 55 West Oak Street Amityville, NY 11701 Amount enclosed: Brick:$ 400.00 Departed Member Brick: $ 75.00 In lieu of a brick, please accept a donation in the amount of: __________ Total enclosed: __________