YES! Engrave my name into Darien History with a personalized Darien Lions Club Pavilion Patio Brick!

Purchaser’s Name

Street Address

City                          State                           Zip

Phone (Home)

Phone (Business)

To order your brick(s) today, fill out and detach the order form and mail it with your payment to:

Darien Lions Foundation
Recognition Brick Patio Program

P. O. Box 2006

Darien, IL  60561

□  Include Check or Money Order. Do not send cash.

Make payable to: Darien Lions Foundation. 
 

Signature

Under Internal Revenue Service guidelines, the full amount of your payment is a deductible contribution.  You will be receiving an additional letter of thanks from the Darien Lions Club Foundation, which is a 501 (c) (3) fully accredited foundation. This should serve as documentation of your gift.

Simply check off the size of brick(s) you are ordering, and print the information exactly as you would like it to appear.  Spaces and punctuation marks count as characters.

Corporate Logos and crests are not
 available on 4” x 8” bricks.

□  4” x 8” Standard Size:  $100

     Max. 21 spaces, 3 lines

□  8” x 8” Standard Size:  $150

     Max. 21 spaces, 5 lines

□  Check here if a corporate logo or family crest is requested. (You will be notified of additional cost that will be required to create the logo.) 

Thank you for your donation!

NOTE:  Use your browser to print this form and fill in all required information.  Mail to the Foundation’s P.O. Box