Request Form

Please fill out this form and
* Print it and mail it with your check or money order of $100 to our home office at this address:

Medina Wedding Chapel
N853 Julius Drive
Appleton, WI 54914-9197
Please call us at 1-800-819-9888 or e-mail us at medinachapel@new.rr.com to confirm that the date you have requested is available before sending in your deposit.

Today's Date:
E-Mail Address:
Names (Bride & Groom):
Street Address:
City, State, Zip:
Home Phone: Business Phone:
Wedding Date: Day of the week:
Time of Ceremony:
Rental Hours: We would like to reserve the church from to
For example: You might have a 4:00 ceremony and rent the church from 3:00 to 5:30
We will locate a pastor/judge for your wedding. Which would you prefer?

Description	Total
Your Wedding Ceremony at the Medina Wedding Chapel	$625.00
Videotaping ($45)
Unity Candle ($20)
Aisle Runner ($20)
Window Candles 16 pcs ($30)
Wedding Programs ($45)
Subtotal
5% Wisconsin sales tax
Total
Subtract $100 non-refundable deposit to reserve date	-100.00
Balance due
Balance must be paid one week before ceremony Date due

Note: If this page is sent by mail, a confirmation letter will be sent back to you showing deposit paid, balance due, date due, wedding date and time, and any options you may have added. If it is returned in person, a copy will be made of this page at that time for your records.