PIHS Student Council Tribute Bricks Project Order Form

(Only one order per form, please.)

    Name:
    Mailing Address:
    City & State: Zip:
    Daytime Phone: Evening Phone:
    Date of Purchase:
    Send Commemorative Certificate of Purchase to: (if different from above)
    Name:
    Mailing Address:
    City & State: Zip:
    INSTRUCTIONS: You may enter only one letter, number, punctuation mark or space per box. ALL engraving requests are subject to approval.
                                           
                                           
                                           
    Letter arrangement will be set up by a graphic artist for maximum visual appeal
    Please... one order per form only.
    Payment Information:
    Individual brick price = $50.00 (Please remit with order form)  
    Total:  
    Please make checks payable to "PIHS Europe Program"
    Do not send cash in the mail
    Mail this form to: Tribute Brick Project
    c/o Eric Waddell
    Presque Isle High School
    16 Griffin Street
    Presque Isle, ME 04769


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