ESHS Rebel Countdown   
Gift Brick Form

To order your "Gift Brick", please print this form, fill in your information and 
mail it in along with your check or money order made payable to; 
ESHS Rebel Countdown.  
If ordering more than one (1) brick, print another 
copy of this form, complete the 'Name' line and the 'Brick Message' section 
only and attach it to the first form you printed.  

Gift Brick Order Form
% Charlsie Smith
303 North 26th Street
Gadsden, AL 35904

Name (Please include your maiden name) ______________________________________

Address  ________________________________________________________________

City _____________________________________ State _________ Zip _____________

Phone Number(s) _________________________________________________________

Email Address ___________________________________________________________

Graduating Class __________________

Number of bricks ordered:  _____   x   $75.00  =   _________ 


You may place a message on your brick. It may be up to 3 lines long.
Each line may contain up to 20 characters, including spaces. 

Brick Message (Start message letters INSIDE first set of marks)

1: |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |

2: |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |

3: |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |



Thanks for your donation!

Emma Sansom High School Alumni