BRICK ORDER FORM

MINIMUM DONATION: $50.00 PER BRICK

(NO MORE THAN 14 SPACES OR LETTERS PER LINE)

 

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IS BRICK TO HONOR________________________ OR

MEMORIALIZE_____________________________

 

NAME (MAKING DONATION)___________________________________________________________

ADDRESS_____________________________________________________________________________

PHONE NUMBER______________________________________________________________________

NAME (SEND ADDITIONAL ACKNOWLEDGEMENT TO NEXT OF KIN)

______________________________________________________________________________________

ADDRESS_____________________________________________________________________________

 

DONATIONS TO:

THE MASURY ESTATE BALLROOM RESTORATION FUND (A 501C3 ORGANIZATION) ARE TAX DEDUCTABLE

MAIL TO:

THE MASURY ESTATE BALLROOM RESTORATION FUND

P.O. BOX 299

CENTER MORICHES, NEW YORK  11934