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2. ENGRAVED BRICK DONATION FORM
4. First Name*
5. Last Name*
7. Address1
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email Address
16. Brick Message

    Enter the exact message that will be engraved in the brick in the space below. Each brick accommodates 3 lines of 13 characters per line, including blank spaces.

18. Line 1
20. Line 2
22. Line 3
24. Thank you for your support of the Flossmoor Public Art Program!

    Please remember that your online brick order will not be processed until your cash or check payment of $125 is received by the Village of Flossmoor. Please ensure your phone number is on the check and the memo line states Brick Donation. Payment can be dropped off in-person during Village Hall business hours. You can also mail your payment to: Village of Flossmoor Brick Donations, Village Manager's Office, 2800 Flossmoor Road, Flossmoor, IL 60422. Please contact Info@Flossmoor.org with questions.

    ***Double check your spelling. The Village of Flossmoor will order the brick exactly as specified and will not replace bricks if the error is not the Village's error.***

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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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