Bricks are available in:

• 3/4" lettering, 3 lines per brick with up to 14 letters
(including spaces) per line.

5/8" lettering, 4 lines per brick with up to 16 letters
(including spaces) per line.

(Circle your choice of size.)

Order Form: (PLEASE PRINT CLEARLY)

Line 1: __________________________________________

Line 2: __________________________________________

Line 3: __________________________________________

Line 4:___________________________________________

Your Personel Information

Name: _________________________________________

Phone: __________________________________________

Address:____________________________________________

Price: $35.00 per brick, due on order. This is a tax-deductible donation.
Check or Money Order only. Make Payable to, and Mail to:

Fill out this form - Print it - Enclose it with your check and mail to,

Waller County Historical Society
PO Box 971
Hempstead, TX 77445