Printable Brick Form:

YOU CANNOT FILL THIS OUT ONLINE ... IT MUST BE PRINTED!!!

Make check out to -- Clive Historical Society
 Send to:  
Clive Historical Society
Brick Walk 
PO Box 22043
Clive, IA  50325


Name __________________________

Address ___________________________
City _______________ St. _____________  Zip _______

Phone Number _____-______-_________

e-mail address ______________________

Check No.   ________   for $50.00 

"Message selection: The brick can be imprinted with three lines of up to 15 characters each (including spaces).  Please print (with capital letters) the name or message you would like on your special Glen-Gery brick in the boxes below. Glen-Gery reserves the right to choose type size and arrange words to maintain balance and legibility"

You need not use all three lines, but three lines are available.  
                             
                             
                             
 

SAMPLE:

B O A  R D   O F F I C E R S  
J I M   -   L E S            
S H A R O N   -   L I N D A  

Would look like this on the Brick

BOARD OFFICERS
JIM - LES
SHARON - LINDA

THANK YOU for your order!