Annie’s Playground Brick Order Form Thank you for your interest in purchasing a Memorial Brick to become a permanent part of Annie’s Playground. Please note that on 8” X 8” bricks, up to three graphics are included in the price and will be placed above the lettering. Total I would like _______ 4” X 8” bricks @ $50.00 each (3 lines of 15 spaces) _________ I would like ________ 8” X 8” bricks @ $100.00 each (4 lines of 15 spaces) *Up to three graphics free with large brick order. _________ NOTE: Each line of text allows for 15 spaces including characters, punctuation, and spacing. PLEASE PERSONALIZE YOUR BRICK IN THE SPACES BELOW: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ GRAPHICS PREFERENCE (Please check) #1. Flower _____ #2. Heart _____ #3. Butterfly _____ #4. Cross _____ Please add #’s _____ _____ _____ Graphics to my brick PURCHASER INFORMATION: Name: _____________________________________ Address: ___________________________________ ___________________________________________ Home Phone: _______________________ Cell Phone: ______________________ Email Address: _________________________________ RETURN THIS ORDER FORM WITH YOUR CHECK OR MONEY ORDER MADE PAYABLE TO: Pics-E Productions MAIL TO: PHONE: Lorene Tompros 4004 Manor Oaks Road Phoenix, MD 21131 410-428-6717 (Cell) 410-510-7305 (Home) A portion of the proceeds from the bricks will be donated to Annie’s Playground for improvements and maintenance. Please allow 60 – 90 days for ordering and installation of your brick. You will be notified when your brick is installed and a photo of your brick will be e-mailed to you. If any questions, please call Lorene Tompros. Thank you for your order! For information on Annie’s Playground at Edgeley Grove Farm Park: www.anniesplayground.net For information on Video Services, Tape Transfer Services, etc, and Books available for purchase: www.picseproductions.com The Magic of Words Collection Written by Lorene Cumpston Tompros in Memory of her Niece Annie McGann Cumpston 1. Trampoline Angel Annie and the Visit to Heaven To Order: www.authorstobelievein.com 2. An Angel’s Embrace – A Journey Through Grief & Recovery To Order: www.picseproductions.com