Brick Campaign Form

Your Inscription:

Your inscription must fit into the white boxes below, one character per box. Please fill in the places as you want them to appear on your brick(s). For multiple bricks use a separate form for each brick. Each brick can have three lines with a maximum of 14 characters per line. A character is defined as a letter or number, a space or punctuation mark. Leave a space between names and before and after an "&" (ampersand).

Payment Information:

Number of Bricks x $100 = $

Name:

Address:

City:

State:

Zip:

Phone:

Email:

If you choose to pay by credit card, a link to enter your card information will be sent to you at the email address you provide.

If you are not paying by credit card, please send a printed copy of this completed form, along with check or cash, to:

Carroll Community College Foundation
1601 Washington Road
Westminster, MD 21157

Method of Payment - Please check one:

Check Cash Credit Card

Please review your request before submitting. For more information or assistance please call the Carroll Community College Foundation at 410-386-8168, or email Diane Yerkey.

Carroll Community College

http://www.carrollcc.edu