Motorcycle Riders Memorial

For those who have fallen, but never will be forgotten.

Memorial Wall Application

Please be sure to add the information where provided for your deceased loved ones brick information. We will need a contact number or address to double check and send out a certification of membership once completed. Please double check all your information.

You must be a member to request a memorial brick.             **Membership is only a one time $10.00 fee       

$100.00

$1000.00 min.

Your Name:

Your Address:

Contact Phone:

Your E-mail:

Method of Payment

Print, include payment and Mail to:

Motorcycle Riders Memorial

PO BOX 1285

Benton, IL 62812

$5000.00 min.

Name, date of birth & death

Was death on motorcycle?

YES

NO