The Indian and Forest Acres Scholarship Foundation

*First Name:

*Last Name:

Your Company:

*Street Address:

*City:

*State/Province: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip code:

*Phone Number:

*Email Address:

*Clip Art/Logo/Artwork?: YES NO

*Brick/Tile Size: Select Brick/Tile4x8 brick(4x8 Gray Forest Acres) -$2004x8 brick(4x8 Gray Forest Acres (Alumni Under 35 y/o)) -$1754x8 brick(4x8 Gray Indian Acres) -$2004x8 brick(4x8 Gray Indian Acres (Alumni Under 35 y/o)) -$1758x8 brick(8x8 Beige Forest Acres) -$3758x8 brick(8x8 Beige Indian Acres) -$37512x12 brick(12x12 Beige Forest Acres) -$57512x12 brick(12x12 Beige Indian Acres) -$575

Would you like to receive a Replica: 1 For - $50.00 2 For - $100 3 For- $150 4 For- $200 5 For- $250 6 For- $300 7 For- $350 8 For- $400 9 For- $450 10 For- $500 NO

Additional Contribution:

*Total Amount($):