Check One:
  $250: One inscribed brick and one commemorative wedge piece with AOF tower etching.
  $150: One inscribed brick (for current students/alumni who graduated within 4 years)

Payment Option:
  Check (Please make checks payable to "Avon Old Farms School")
  Visa
  Mastercard

Credit Card Information:
Expiration Date: _ _ /_ _
Card Number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

Cardholders Signature:
_______________________________________________ Date: _________
 
Date: ____________

Your Name: ______________________________________________________

(As you want your name inscribed on the brick)
Your Class: ________

Your Address: _____________________________________________________

City: ______________________________ State: _________ Zip Code: ________

Home Telephone: (_____)- ______ - ________

Please return this form and chosen payment to:
Avon Old Farms School
Alumni/Development Office
Attn: Rob Dowling
500 Old Farms Road
Avon, CT 06001
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