If you would like to mail the form  click here for a printable version.

Fields marked with a * are required.

Contact Information

*First Name:
*Last Name:
*Address:
*City:
*State/Province:
*Country:
*ZIP:
*Phone:
*email:

Brick Information

Brick (4 X 8) $75.00 each:
Replica Brick (4 X 8) $40.00 each:
Brick (8 X 8) $150.00 each:
Replica Brick (8 X 8) $80.00 each:
Granite Paver $500.00 each:
Each line is limited to 14 capitalized letters / characters. Each line counts spaces and punctuation as characters.
Line 1:
Line 2:
Line 3:
(8 X 8 Brick Only) Line 4:
(8 X 8 Brick Only) Line 5:
Choose Image: (8 X 8 Brick Only. 5th line of text not available if image is chosen)
None

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By clicking the "Submit" button below, you commit to buy from The City of Sturgis Rally Department and you will be directed to paypal to make your payment.