Contact Information
* Name
Company Name
*Address
*City *State *Zip
*Phone Fax
*Email
* Required
Order Guidelines
  • All text will be centered
  • Maximum 18 characters per line
  • All inscriptions subject to approval by Heritage Square Trust
  • $65 for the first line, $10 for each additional line
  • Maximum 3 lines
  • To purchase multiple bricks with the same inscription, increase your quantity ordered in the PayPal shopping cart
  • To purchase multiple bricks with different inscriptions, you must place individual orders for each
  • You will receive a certificate for confirmation in the mail.
Brick Inscription
Line 1 Line 2 Line 3

I have read and agree to the following disclosure statement: I approve the above names for correct spellings and understand that bricks will be placed in random order sold. I further understand that each group of bricks purchased will be laid together, but that the location is at the full and absolute discretion of the committee.
If you would prefer, you can also download this form and e-mail it directly to info@heritagesquaretrust.org.

© Heritage Square Trust 2006
Web design by Derrsign, Inc.