Springfield Humane Society, Inc.

Memory Lane

Each brick will be engraved in ALL CAPITAL LETTERS, or in both upper and lower case letters,

which will appear black on the bricks. Be sure to print carefully so we can tell which it is you want.

The 4X8 bricks cost $50 for one line, $75 for two lines or $100 for 3 lines.

The 8X8 bricks cost $100 for one line, $150 for two lines, or $200 for 3 lines.

All proceeds raised from this project will help care for the animals at the Shelter.

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Yes, we’d like to reserve a permanent brick(s). Please engrave our brick(s) as follows:

ANY SYMBOL IS CONSIDERED ONE SPACE (PERIOD, COMMA, DASH OR BLANK SPACE)

ALL TEXT IS CENTERED UNLESS OTHERWISE NOTED

4 x 8 Brick

8 x 8 Brick

EXAMPLE (Remember everything will be centered on the brick)

I

N

M

E

M

O

R

Y

O

F

M

O

R

I

A

H

&

M

O

L

L

Y

B

R

O

W

E

PLEASE RETURN THIS FORM AND YOUR CHECK PAYABLE TO:

Springfield Humane Society, 401 Skitchewaug Trail, Springfield, VT 05156 If you have questions call Tom 885-2174

Name: ________________________________________ Phone: (_______) _________________________
Address: _______________________________________________________________________________

City: ____________________________________ State: __________________ Zip: __________________

Email Address: ___________________________________________ Amount Paid: ___________________

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