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Brick Order Form

Last Name  ___________________________   First Name ___________________________

Organization's Name (if applicable) ________________________________________________

Address ___________________________________  City _____________________

State _______ Zip ______

Telephone Numbers -- Home ____________________  Work __________________-

$50 Brick

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____    ____    ____     ____    ____    ____     ____    ____    ____     ____    ____    ____

Each line has 12 Characters. (Spaces = characters)

Please enclose your check or money order and mail your order form to

Marquette Park Playground Committee
P.O. Box 2861
Gary, IN 46403

Thank you for your kind support of this project.

Contact Nora Glenn at
nglenn@netnitco.net
with any questions or concerns.

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