EmailMe Form - Berkeley Springs Brick Fundraiser!!!

Please note that payment has been disabled on this form.
You may notify the owner and continue to submit the form.

Choose Your Brick *
4” x 8” bricks can be personalized with up to 3 lines of text 20 characters per line without clipart or 16 characters with clip art.
8” x 8” bricks can have up to 5 lines of text , 20 characters per line with or without clip art.
Add $25 for clip art.
Mini Replica bricks to remember your donation are $25 each additional.
Line 1:
Must be between 0 and 20 characters, currently: 0.
Line 1:
Must be between 0 and 16 characters, currently: 0.
Line 2:
Must be between 0 and 20 characters, currently: 0.
Line 2:
Must be between 0 and 16 characters, currently: 0.
Line 3:
Must be between 0 and 20 characters, currently: 0.
Line 3:
Must be between 0 and 16 characters, currently: 0.
Line 4:
Must be between 0 and 20 characters, currently: 0.
Line 5:
Must be between 0 and 20 characters, currently: 0.
Choose Your Logo
Name *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Phone *
### - ### - ####
Email *