CC#: ______________________________________________________________________________ Exp Date: __________________ CVS#: _________

Signature: _________________________________________________________ Email: _____________________________________________________

Please PRINT NAME: ______________________________________________________________________________ Date: ______/______/________

Company/Organization (if appropriate):* ________________________________________________________________________________________

Name(s):* ____________________________________________________________________ Title: _________________________________________________

Address: _____________________________________________________________________________________________________________________________

City: ________________________________________________________________________ State: _____________________ ZIP Code: _________________

Telephone: __________________________________________ Email: ________________________________________________________________________

Signature Authorizing This Order:* __________________________________________________________________ Date:* ______/______/_______

CAPITAL CAMPAIGN BRICK PAVER ORDER FORM

[ ] Personal Gift or [ ] Corporate Gift (check one)

Credit Card (check one): [ ] Visa [ ] Master Card [ ] Amex

Please make checks payable to: YMCA OF SAN ANGELO (Memo: Capital Campaign)Mail: YMCA OF SAN ANGELO, Capital Campaign, 353 S. Randolph St., San Angelo, TX 76903

Scan/Email: lmata@ymcasanangelo.org

Questions about your order? Contact Linda Mata at (325) 655-9106 or lmata@ymcasanangelo.org.

For Office Use Only

Appeal Code: ________________________ | Date Order Entered: ______/______/______ | YMCA Staff Initials: ________________

YMCA OF SAN ANGELO is a 501(c)(3) tax-exempt organization. Gifts are tax deductible to the extent provided by law. EIN: 75-0800698

DONATION GRAND TOTAL:

$ ___________________________

A SNAPSHOT TODAY,THE BIG PICTURE TOMORROWCAPITAL CAMPAIGN OF YMCA OF SAN ANGELO

Brick pavers are an excellent way to support the Capital Campaign of YMCA of San Angelo! The YMCA’s goal is to raise $7.5 million to construct a second location at 2833 College Hills Boulevard to accommodate the Little Explorers Preschool Program, Day Camp, and Summer Camp. The need arose due to the increasing demand for YMCA’s preschool and other childcare programs. Along with renovating the existing 11,000 square foot facility, and constructing a new 12,000 square foot multi-use center, a brick walkway will be installed. For a donation, a personal message will be engraved on the brick size of your choosing. Please show your support to the YMCA by purchasing your brick(s) TODAY!

[ ] 4” x 8” = $100

[ ] 8” x 8” = $500

[ ] 12” x 12” = $1,000

Choose Your Brick(s):*

How many bricks of this size? __________ | Total Cost: $_____________

How many bricks of this size? __________ | Total Cost: $_____________

How many bricks of this size? __________ | Total Cost: $_____________

Add your personalized message on the back of this form.

ONLINE ORDERING AVAILABLE AT WWW.BRICKSRUS.COM/DONORSITE/YMCASANANGELO

This page may be copied if ordering more than one paver. per size.White boxes indicate the recommended spaces.

Please print one character per box.Punctuation and symbols count toward the character count.

[ ] 4” x 8” - $1004 lines (3 recommended) | 21 characters per line (18 recommended)

[ ] 8” x 8” = $5008 lines (6 recommended) | 21 characters per line (18 recommended)

[ ] 12” x 12” = $1,00012 lines (10 recommended) | 25 characters per line (23 recommended)

A SNAPSHOT TODAY,THE BIG PICTURE TOMORROWCAPITAL CAMPAIGN OF YMCA OF SAN ANGELO

PLEASE CHOOSE BRICK SIZE(S):*

YMCA OF SAN ANGELO is a 501(c)(3) tax-exempt organization. Gifts are tax deductible to the extent provided by law. EIN: 75-0800698

ONLINE ORDERING AVAILABLE AT WWW.YMCASANANGELO.ORG