Titan Terrace Brick Order Form

Name:____________________________________________________________
Address:__________________________________________________________
City:____________________________________________ State:_____________

Zip:______________  Phone:________________  Alternate Phone:___________

E-mail address:_____________________________________________________

Select your text for a 4" x 8" Brick:

      Brick # 1 - 4" x 8"- 3 lines of 18 characters per line.
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

      Brick # 2 - 4" x 8" - 3 lines of 18 characters per line.
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

 Select your text for an 8" x 8" Brick:

      Brick # 1 - 8" x 8" - 5 lines of 18 characters per line
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

      Brick #2 - 8" x 8" - w/WF logo - 3 lines of 10 characters per line
      __ __ __ __ __ __ __ __ __ __ 
      __ __ __ __ __ __ __ __ __ __
      __ __ __ __ __ __ __ __ __ __

 _____4" x 8" bricks @ $30/brick =                      $___________
 _____8" x 8" bricks @ $60/brick =                      $___________
 _____8" x 8" bricks w/titan logo@ $75/brick = $___________

Enclosed is a check for $_______ payable to West Forsyth High School PTSA. Your check will serve as your receipt.

Mail to:  West Forsyth PTSA 
             1735 Lewisville-Clemmons Rd.
             Clemmons, NC 27012

Thank you for your order!