Solace Garden Order Form - Hospice of Central New York & of the Finger Lakes

Solace Garden Engraved Bricks

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

First name*

Last name*

Phone

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

In Memory Of

First Name Last Name

In Honor Of

First Name Last Name

Your relationship, if any, to the honoree

Who would you like to be notified to acknowledge your brick donation? Please write full name and address. (Please Note: The amount of your gift will NOT be included in the notification.) :

Solace Garden Bricks Sizes:*

$150 - (4x8) Brick

$250 - (8x8) Brick

Brick add-ons:

Graphic (See most popular graphic options below, price per graphic)

If you would like a Replica Brick(s) to add (Please note that each brick will be an additional $25):

Price: $25.00

Please use the space to personalize your brick. The 8x8 brick can have up to 5 lines and the 4x8 brick can have up to 3 lines. Both bricks should have no more than 20 characters per line. **Any symbol is considered one space. For example: (dash, period, space, etc.)

If you would like a graphic on your brick please note this will be an additional $25. Please indicate which graphic you would like here:

Total

You do not have to have a Paypal account. Click on the Paypal button and then choose the Pay with Debit or Credit Card button.

Payment Method*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Solace Garden Brick Order Form

Solace Garden Engraved Bricks