Brick Order Form
Name: __________________________________________________________
Mailing Address: _________________________________________________
________________________________________________________________
________________________________________________________________
Phone Number: ___________________________________________________
Send your tax deductible check or money order to:
Southern Maryland Carousel Group, Inc.
Post Office Box 2335
La Plata, MD 20646
Number of 4" x 8" bricks: ___________
Number of 8" x 8" bricks: ___________
Inscription: One-, two-, or three-line inscription for each brick. Each line must be no longer than 15 characters including spaces. If additional lines for inscriptions are needed, please use a blank sheet of paper and attach to order form.
Brick No. 1
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Brick No. 2
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Brick No. 3
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