East Mountain Neighborhood Association

We are raising money to build a new walkway in our new park.
4 X 8 Brick - $50.00 8 X 8 Brick - $100.00
Please use ALL CAPITAL Letters!
4 X 8 brick =3 lines maximum with 13 spaces/letters per line
8 X 8 brick = 6 lines maximum with 13 spaces/letters per line
Yes, we would like to reserve a permanent brick. Please engrave our brick as follows:
ANY SYMBOL IS CONSIDERED ONE SPACE (PERIOD, COMMA, DASH)
ALL TEXT IS CENTERED UNLESS OTHERWISE NOTED

Yes, we’d like to reserve a permanent brick. Please engrave our brick as follows:

ANY SYMBOL IS CONSIDERED ONE SPACE (PERIOD, COMMA, DASH)

ALL TEXT IS CENTERED UNLESS OTHERWISE NOTED

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PLEASE RETURN THIS FORM AND YOUR CHECK PAYABLE TO:

East Mountain Neighborhood Association

c/o Jean Guisto

31 Brackenridge Drive

Waterbury, CT 06706

Name: ________________________________________ Phone: (_______) _________________________

Address: _______________________________________________________________________________

City: ____________________________________ State: __________________ Zip: __________________

Email Address: ___________________________________________ Amount Paid: ___________________

If you have any questions, please call :

Nancy Ptak – 754- 9311 or Debbie Langdon – 756-0749