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Complete the bottom portion of this paper and return the form to the Venice Moose Lodge with a check for $25.00 per brick. Each brick may contain a maximum of 18 characters per line with a limit of 4 lines. A space counts as a character.

EXAMPLE:

 

Complete information below as you would like it to appear on your brick –and return with $35.00 to
Venice Moose Lodge,  ATTN. Moose Legion Brick,  111 N. Auburn Rd.,  Venice, FL 34293.