Bricks for Badges

Printable Brick Order Form

Please print and fill out

Name ___________________________________________ Date _________________

Address ________________________________________________________________

Day Phone ________________________ Night Phone __________________________

E-Mail _________________________________________________________________

When personalizing your brick, please refer to these guidelines:

• There are 3 lines per brick, 20 characters per line.

• Each letter, space, punctuation mark or number counts as a character.

• Letters may be in upper and lower case.

• Acceptable punctuation marks are: ~ ! @ # $ % ^ & * ( ) + = : ; " ' < > , . ? /

• All text will be automatically centered on each line - you need not center it below.

• No inappropriate language will be accepted.

• Please print clearly.

Please personalize my brick as follows:

Donation

One 4" x 8" brick and one mini-brick (1½" x 3") = $ 150.00

Additional mini-bricks ($15 each) _______ x $15.00 = $ ___________

Reserved location* # ___________ ($50.00) = $ ___________

TOTAL (add lines 1 through 4) = $ ___________

* See the "Brick Location Chart" for choices,

then call Sam @ 504-717-1529 to confirm a location.

Please make check payable to COPS 8 and drop off/mail to: Bricks for Badges

334 Royal Street

New Orleans, LA 70130

If paying online via Paypal, check here: _____

Form may be faxed to 504-523-2336.