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Memory Brick Order Form

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St. Mary Memory Bricks
We invite you to be a remembered part of our history. Commemorate Anniversaries, Baptisms, Births, Graduations, Marriages, Memorials, Thank You's and much more.

When you participate in the Make Your Mark Program, you are contributing to our Parish and School buildings and grounds improvements. Thank you for supporting St. Mary of the Immaculate Conception!

● Bricks will be located throughout the parish and school grounds - currently placing them in front of church

● Please complete & submit our Online Form along with your payment or you may download a form and turn in to the Parish Office

If you have questions, please email Mary Jane or call her at 408.354.3726 x110
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Select ONE Size of Brick (Create separate orders for multiple bricks) REQUIRED 500 – 4 x 8 Brick ( 3 Lines) 1000 – 8 x 8 Brick (6 Lines) Please fill out this field.
- Limit of 23 characters per line. Orders are case sensitive. Spaces and punctuation count as characters
- Line 1 REQUIRED
  Orders are case sensitive. Spaces and punctuation count as characters
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- Line 2
  Orders are case sensitive. Spaces and punctuation count as characters
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- Line 3
  Orders are case sensitive. Spaces and punctuation count as characters
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- Line 4 (8x8 brick only)
  Orders are case sensitive. Spaces and punctuation count as characters
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- Line 5 (8x8 brick only)
  Orders are case sensitive. Spaces and punctuation count as characters
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- Line 6 (8x8 brick only)
  Orders are case sensitive. Spaces and punctuation count as characters
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