<<BACK                                   Brick Purchase Form:

Bricks & Sticks
 for
145 Baker Street

To order your brick (s), please select from the
 options below, bricks can have a maximum of
 14 characters per line.

 Bricks - 4 x 8 =  2   Lines

A character is defined as a letter or number,
a space or punctuation mark.

        1 Brick @ $100.00 each - $100.00
      2 Bricks @ $100.00 each - $200.00
      3 Bricks @ $100.00 each - $300.00
      4 Bricks @ $100.00 each - $400.00
  ___ Bricks @ $100.00 each - $_____

                                            Total: $_______

 

Name: ___________________________________________

Address:  _______________________________________

_______________________________________________

_______________________________________________


Phone___________________

Please Inscribe My Brick With:
 

___________________________

___________________________

___________________________
 

Method of Payment
Please send this completed form, along with check or  money order, payable to:
Habitat for Humanity of Winchester-Frederick County
  P.O. BOX 1653    Winchester, VA 22604