Donor’s Last Name:
Shrine of Our Lady of the Island
258 Eastport Manor Road
Manorville, NY 11949
The Founders Way Brick Walk Program
____
CHECK IF WHITE BRICK (NO CLIP ART) 4 x 8 Brick
Donor’s Last Name:
Shrine of Our Lady of the Island
258 Eastport Manor Road
Manorville, NY 11949
The Founders Way Brick Walk Program
____
CHECK IF WHITE BRICK (NO CLIP ART) 4 x 8 BrickCLIP ART #_____ DO NOT USE SHADED AREA IF CHOOSING CLIP ART
8 x 8 BrickCLIP ART #_____ DO NOT USE SHADED AREA IF CHOOSING CLIP ART
Name:__________________________________Tel #: ____________
Address:______________________________________________
City:_____________________________ State: ____ Zip:__________
E-Mail : _________________________________________________
Office Use Only:
White Brick: $1004x8: $50 OR 5 FOR $200 OR 8X8: $150
Date:______ Amt: _______ Check #_________ Staff Initial:______
Computered Generated ID #:
__________ Admin/Memorials/Forms/Brick Walk Forms/ONE FORM Revised 11-17-08