Wachovia Center - - Bricks Order Form

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Bricks Order Form

Fill in this form and fax it to (215)952-5724 or mail to:

The Walk at the Wachovia Center
3601 S. Broad St.
Philadelphia, PA 19148

Please reserve:

Brick Paver(s) at $75.00 each and/or

Signature Brick(s) at $100.00 each

I'd also like:

Replica Brick(s) at $39.55 each (includes shipping and tax)

My Paver(s) should be
inscribed as follows:

Line 1:

Line 2:

The inscriptions are limited to 15 characters per line on two lines.
Please be sure to count blank spaces and punctuation marks as characters.

I would like my Signature Brick(s) placed near to the following autograph:

Name:

*Those ordering replica brick, please add street address in addition to P.O. Box number or RD number. UPS will not deliver without a street address.

Address:

City:

State:

Zip:

DaytimePhone #:

Method of Payment:

Visa	Mastercard
American Express	Discover

Card Number:

Expiration Date:

Name as it appears on the card:

Signature:

Fill in this form and fax it to (215)952-5724 or mail to:

The Walk at the Wachovia Center
3601 S. Broad St.
Philadelphia, PA 19148

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