Use your browser's print function to print out this order form. Complete it and send it with your check to:

University City Historical Society
P.O. Box 31927
Philadelphia, PA 19104

Please send a date marker for:

• Powelton Historic District
• West Philadelphia Streetcar Suburb Historic District
• Garden Court Historic District

at $15 (UCHS member) or $25 (non-member) for the following address:

____________________________________________________________
using the date of construction indicated in the district nomination.

The plaque should be delivered to

Name: _______________________________________________________

Address:______________________________________________________

_____________________________________________________________

Phone:_______________________ E-Mail___________________________

I am/am not interested in free installation by UCHS.

My check for ____________ is enclosed.

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