LEGACY BRICK ORDER FORM

USE A SEPARATE FORM FOR EACH BRICK

 

Printout and mail the completed form(s) and a check for $110.00 for each brick to:
 
The Klyne Esopus Museum
Attn.: Legacy Brick Order
PO Box 751
Port Ewen, New York 12466-0751
PURCHASER’S NAME:

ADDRESS:

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CITY/STATE/ZIPCODE

TELEPHONE NUMBER:
EMAIL ADDRESS:

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PLEASE CARVE THE FOLLOWING LEGACY ON MY BRICK:

(13 characters or spaces per line, three lines per brick. We will center the words for you.)
Text Box:
BRICKS ARE ORDERED TWICE EACH YEAR WITH A DELIVERY TIME OF 8 WEEKS.
Form 9 (June07)