BUY-A-BRICK ORDER FORM

NAME______________________________________PHONE___________________________
 

ADDRESS______________________________CITY__________________ STATE____ZIP___________

I WOULD LIKE TO ORDER #_____4x8 BRICKS  @  $100.00 = $________

                                                   #_____8x8 BRICKS  @  $250.00 = $________

(4x8 brick—Up to 3 lines of text—15 characters per line including spaces and commas)
(8x8 brick—Up to 6 lines of text—15 characters per line including spaces and commas)

                                Please photocopy this application for each additional brick
FOR 4x8 BRICK:

LINE 1 /_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 2 /_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 3/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

FOR 8x8 BRICK:

LINE 1 /_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 2 /_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 3/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 4/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 5 /_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

LINE 6/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/_____/

  ___  I WOULD LIKE TO ORDER A BENCH WITH INSCRIPTION FOR $1,000
                               (For details please call 914-632-2925)

Please make checks payable to:      New Rochelle Humane Society

Mail to:      New Rochelle Humane Society, 70 Portman Road, New Rochelle, NY 10801



                            * A certificate of acknowledgement will be sent to you.