SELDEN CIVIC ASSOCIATION

PO Box 521

Selden, NY  11784

BRICK ORDER FORM

(NO MORE THAN 14  SPACES OR LETTERS PER LINE!)

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 NAME:       ___________________________________________________

ADDRESS: ___________________________________________________

PHONE:      _______________________________________

EMAIL           _________________________________________________

Member cost $30._________________One Brick

Non-Member $40._________________One Brick

Would you like to become a member for $10. a year, you will save on the cost of your brick order and be part of our monthly mailing list to keep you informed of what is new and happening in our Hamlet of Selden. 

If you would like to become a member just enclose your check for $10, along with your brick order and check off here.  I want to be a member._________________

E-mail address—seldencivic@optonline.net

Web-site address—www.seldencivic.org