MEMORIES ON A BOTTLE

Brick order form

We offer two types of bricks. Both are red with flat surfaces. the only difference is one is chamfered. Remember you are allowed up to 16 characters per a line, 3 lines maximum. Spaces count as a character. For an extra $5.00 ($23.00 total), you can include an image. If a image is used, only 9 characters per a line is permitted 3 lines maximum.

E-MAIL ADDRESS(required)

TYPE OF BRICK: QUANTITY: PRICE: IMAGE:

Now let's personalize your brick.

FIRST LINE:

SECOND LINE:

THIRD LINE:

FIRST NAME: LAST NAME:

SHIPPING ADDRESS:

CITY: STATE:

ZIP: COUNTRY:

include area code and country code

DAYTIME PHONE :

HOME PHONE:

FAX:

If you are part of a fund raising effort with prior approval from Memories on a Bottle please list your organization below to assure the 10% donation. If you are not and would like to be, please call (919) 266-0261 for approval

ORGANIZATION:

North Carolina residents are required to pay 6% sales tax. Since all orders are customized, we will call to verify an order. Price does not include shipping or handling. We accept and .

Your comments or recommendations on images is greatly appreciated.

By pressing the submit you agree to our terms and conditions.

FIRST NAME:		LAST NAME:
SHIPPING ADDRESS:
CITY:		STATE:
ZIP:		COUNTRY: