Engraved Brick Application

"*" indicates required fields

Brick Options*

Option 1: Standard 4x8 Brick
COST: $100 per brick, 3 lines maximum, 13 characters per line (Including Spaces)

Option 2: Large 8x8 Brick
COST: $250 per brick, 6 lines maximum (or 4 lines & Lions logo), 13 characters per line (Including Spaces)

Brick Fee Due with Application

Logo:

Yes

Line 1

Line 2

Line 3

Line 4

Line 5

Line 6

Name*

First Last

Address*

Street Address City State ZIP Code

Club/District*

Phone*

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