Key West Art & Historical Society
Brick Order Form

Please print, complete and mail this form to:
Key West Art & Historical Society
281 Front Street, Key West, FL 33040
305-295-6616 or fax this form to: 305-295-6649

Join the Path of Friends -- Be a Part of History!
Purchase a brick and become a permanent part of the legacy of the Custom House. Only $55 per brick

Name: _____________________________________________

Address: ___________________________________________

City/State: ______________________   Zip Code: __________

Phone: _______________  Fax: _________________________

Brick Inscription: (15 characters per line, 3 lines maximum):

__________________________________________________

__________________________________________________

__________________________________________________

Images Available (check one):

Sun  [    ]        Heart  [    ]         Flag [    ]
Cross [    ]         Star of David [    ]       No Image [    ]

Payment Method:

Check Amount: _____________________ Check # _________

Cash: ________

Credit Card Amount: _______ CC#: _________________ Exp. Date: ______

Signature: ___________________________________________