ESU Signature Series Brick Order Form

For complete instructions, please return to the previous page. Please print.

Purchaser's Name: ______________________________________________________________________

Address: ____________________________________________________________________

City: __________________________________ State: _______ ZIP: ____________________

Daytime Phone: (        )________-__________ Evening Phone: (        )________-__________

Fax: (       )_______-_________ E-mail: ___________________________________________

Method of Payment:

Check Enclosed (Make check payable to ESU Alumni Association)

VISA

MasterCard

Account number: _________________________________________ Exp. Date: __________

Name as it appears on card: ____________________________________________________

Signature: ___________________________________________________________________

Brick size:

_____ 4"x8" x $100 = $__________

_____ 8"x8" x $250 = $__________

_____ 12"x12" x $500 = $__________

4"x8" Standard 2 lines - 12 characters per line.*

8"x8" Hornet Signature Brick 5 lines - 12 characters per line.*

12"x12" Black and Gold Edition Brick 7 lines - 18 characters per line.*

*Spaces are counted as characters.
Greek letters are also available (see below).

Please return this completed form to:
ESU Alumni Association, 1500 Highland Street, Emporia, Kansas 66801-5018