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