FHTC Foundation Engraved Brick Form

Please fill out the form and submit or print and send with your contribution to:

FHTC Foundation
Flint Hills Technical College
3301 West 18th Ave.
Emporia, KS 66801

Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:	() -Second partThird part

Engraved Brick Information

4x8 bricks - 3 lines per brick
8x8 bricks - 6 lines per brick
(20 characters per line)

1st Line:
2nd Line:
3rd Line:
4th Line:
5th Line:
6th Line:

Number of Bricks		Total Amount
	4 x 8 @ $ 60.00=	(General)
	8 x 8 @ $120.00=	(General)
	4 x 8 @ $100.00=	(Corporate)
		Logo $75
	8 x 8 @ $250.00=	(Corporate)
		Logo $75

  Camera Ready Logo Ordered

FHTC Foundation Contribution Levels

Company Logo included at no charge!

Prairie Winds Club @ $500.00 =	$
Bluestem Club @ $1500.00 =	$
Flint Hills Club @ $2500.00 =	$

An invoice will be sent for your order.