Buy a Brick - Build a Dream
Application Form

A separate order form must be submitted for each brick.
You may make copies of this form.
Please clearly fill in the blocks and mail this form with payment of $100 per brick to:

Buy A Brick - Build A Dream
81 Norman Dr.
South Windsor, CT 06074

Make your check payable to:
South Windsor Community Foundation
(Please note on the memo line of your check "Buy a Brick")
(First line of inscription - up to 13 characters (letters, numbers, spaces and punctuation marks)
(Second line of inscription - up to 13 characters (letters, numbers, spaces and punctuation marks)
Purchaser Information
Name:_________________________________________
Address:_______________________________________
Town:____________________________
State:___________ Zipcode::_______________
Home Phone:(       ) ____________ Work/Cell Phone:(       ) ____________
 
Check box if you have ordered more than one brick and want to have them grouped together.
Remember each brick requires a separate form.

Any questions, call Buy a Brick subcommittee members:
Lu-Anne Porcello (860) 648-9118 John Pelkey (860) 644-5405

Thank you for your support!

The "My Friend's Place" Core Committee reserves the right to regulate all brick messages.

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