Donate your support!
Questions? Email: info at huberbreaker.org
Thanks for taking the time to print and fill out this Form.
Name ________________________________________
Address ____________________________Apt#_________
City_______________________ State _____ Zip________
Phone # (_____)_____________ E-mail ______________________
Your information will not be shared with any other organization. This form is used for multiple types of orders, please fill out only the information below that indicates your specific purchase.
Check all that apply: Brick____ T-Shirt____ Sweatshirt ____
Bricks:
Please indicate how many bricks you would like of each type:
Plain-no text ($2)x ________ One to Two lines ($50)x________
Three lines ($75)x ________ Logo ($100)x ________
TOTAL = $_______________
The text to be engraved must be less than 12 characters per line, 24 total characters for two lines, and 36 total characters for three lines. All letters and numbers must fit into the following format:
_|_|_|_|_|_|_|_|_|_|_|_
_|_|_|_|_|_|_|_|_|_|_|_
_|_|_|_|_|_|_|_|_|_|_|_
If you would like more than one brick to be engraved, please use the back of this form once printed. Please maintain the format of 12 characters per line, three line maximum.
T-Shirts:
Please choose the size and mark the quantity in the space provided below.
Size (Adult): Small ___ Medium ___ Large___ X-Large ___
# of shirts________ (x$15 ea.)= Subtotal $ ____________
XXL _________ (x$17.50 ea.) = Subtotal $ _____________
Sweatshirts:
Size (Adult): Small ___ Medium ___ Large___ X-Large ___
# of shirts_______(x$22.00 ea.)= Subtotal $ ____________
XXL _________ (x$24.50 ea.) = Subtotal $ _____________
Add each subtotal to get your complete
…………………………………… SHIRT TOTAL $ _____________
S/H [$6 for first shirt, $3 each additional] $ _____________
………………………………….. ORDER TOTAL $ _____________
Send Check or Money Order made payable to:
Huber Breaker Preservation Society
101 South Main St.
Ashley, PA 18706