SIDEWALK PAVER ORDER FORM 4X8" FOR POST ENTRANCE
Contact Information:  Person Placing Brick Order           Control #                                                    
Name:                                                                            Telephone #                                               
Address:                                                                         E-MAIL                                                        
                                                                                                                   
State:                                 Zip Code:                         
Each brick can be engraved with one emblem and up to 3 lines of of text.  Each line can contain up to 20
characters (letters, punctuation, spaces).  If you desire additional bricks for your family, the 2nd Brick
is $75.00 and then $50.00 for each additional family member.  All Letters will be engraved in UPPER CASE. 

                                                                                 
Brick # 1    Emblem             AL                                  AUX                                      SAL
Line 1 Line 2 Line 3

                                                                                                 
Brick # 2    Emblem              AL                              AUX                                      SAL
Line 1 Line 2 Line 3 Comments/Instructions:                                                                                                                                                                                                                   
                                                                                                                                                                       
Cost per Brick (first two)    $75.00        No. of Bricks Ordered:                           Subtotal:$                            
Each additional Brick          $50.00       No. of Bricks Ordered:                           Subtotal:$                           
                                                                                                                                Total:$                           
Make Checks Payable to:                                                      Received by:                                                     
Hardin Post 113 Building Fund                                                   Check #                                                        

                                                                                        
Brick # 3    Emblem             AL                                AUX                                         SAL 
Line 1 Line 2 Line 3

                                                                                                            
Brick # 4    Emblem            AL                                AUX                                        SAL 
Line 1 Line 2 Line 3

                                                                                                            
Brick # 5    Emblem           AL                                 AUX                                       SAL 
Line 1 Line 2 Line 3

                                                                                                             
Brick # 6    Emblem           AL                                 AUX                                      SAL 
Line 1 Line 2 Line 3