Charleston Carnegie Public Library Donor Brick Application
To order an engraved brick for the Kids Space patio, please complete this form or call 217-345-4913
For multiple brick orders, please use additional forms or attach additional information to this form.

Purchaser's Name: _______________________________________________________________
Address: ___________________________________________________________________
City _______________________________________ State ____________ Zip ____
Day Phone _____________________________ Eve Phone_________________
Email ___________________________________________________________________
Check here if this brick donation is a gift.
Please send a gift card to:
Name: ___________________________________________________________________
Address: ___________________________________________________________________
City _______________________________________ State ____________ Zip ____
Message for gift card:
___________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________________________________________________

Inscription
Message lines available on 4" x 8" brick (No more than 12 characters or spaces per line, all letters are capital letters.)
Line 1 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Line 2 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Line 3 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Size Cost per brick Number ordered Subtotal amount
4" x 8" $50.00
Total amount of brick order: $______________