EmailMe Form - Kora Shriners Buy a Brick Fundraiser

Choose Your Brick *

4” x 8” bricks can be personalized with up to 3 lines of text , 20 characters per line without clip art or 16 characters with clip art.

8″ x 8″ bricks can be personalized with up to 5 lines of text , 20 characters per line with or without clip art.

Click to display or hide clip art.

Please add clip art (Add $25)

Please include a Mini Replica Brick for my home or office (Add $25)

Line 1:

Line 2:

Line 3:

Line 4:

Line 5:

Choose Your Clip Art

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone *

### - ### - ####

Email *