Brick Paver Order Form

Brick Paver Order Form
Purchaser Name

First NameLast Name
Purchaser E-mail
Purchaser Contact Number

Area CodePhone Number
Purchaser Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Each 5"x10" paver has the abilty to contain 4 lines, 16 characters long each for a total of 64 characters.

Engraving will be done in all CAPS and font chosen by the Naperville Jaycees.

Please keep in mind that letters, numbers, punctuation and spaces are considered characters. We will contact you with a proof within 72 business hours.
BRICK #1: Please type your inscription as you would like to see it here.
BRICK #2: Please type your inscription as you would like to see it here.
BRICK #3: Please type your inscription as you would like to see it here.
If you feel comfortable doing so, please share a bit of information with us relating to this purchase.
How did you hear about this program?

Purchasing as a Gift?

YesNo
Recipient Full Name

First NameLast Name
Recipient Email
example@example.com
Installations will take place quarterly as weather allows. More details will be sent to you after your purchases.
If this is a gift, please detail delivery instructions in "additional requests" below.
Additional Requests

Order

(1) Engraved Brick Paver $275.00

Get a 5"x10" Eco Priora Brick Paver

(2) Brick Paver Discount$500.00

Get (2) 5"x10" Eco Priora Brick Pavers for $50 off

(3) Brick Paver Discount$725.00

Get (3) 5"x10" Eco Priora Brick Pavers for $100 off!

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country