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Leave Your Mark In the Park

Engraved Brick Order Form

L.P. Grant Park



Engraved Brick Project



Thoughts Lead to Play


Purchaser's Information:


Name


Business Name (if applicable)


Address


City                                                               State                                              Zip


Phone


email


Type of Brick


____ Family ($75 per brick)   ____ Business ($150 per brick)  ___ Total # of Bricks in this order  ___ $ Enclosed


Engraving on Brick


One brick accommodates two lines of text with two to fourteen characters per line.


First Line: ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___


Second Line: ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___


Form of Payment


___ Cash     ___ Check (check #_____________)     ___ Money Order


(checks/money orders payable:  Grant Park Conservancy - Playground)


___ Credit Card (circle one:  VISA,    American Express,     MasterCard)


Name on Card:


Card Number:


Expiration Date:


Signature


 


 
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