Commemorative Brick Order Form

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Commemorative
Brick Campaign Order Form

Purchaser Name ________________________________________________________________

Address_______________________________________________________________________

City, State, Zip__________________________________________________________________

Phone______________________________ Email______________________________________

Brick information (please complete your wording selection(s) in the space below

Brick Size	No. of Lines	No. of Characters per Line	Price Each	Quantity	Total
4 x 8	Three	Fourteen (14)	$100	________	________
6 x 9	Four	Twenty-One (21)	$300	________	________
12 x 12	Nine	Twenty-One (21)	$550	________	________

Create Your Own Brick
Please complete the boxes with the wording exactly as you would like it to appear on your brick. A space should be left between names and on either side of "&".
This includes spaces and punctuation such as hyphens, apostrophes and periods

Please make your check payable to Althoff Catholic High School.

Send completed form to Althoff Development Office - 5401 West Main Street, Belleville, IL 62226