Name:_________________________________________________________________________

Address:_______________________________________________________________________

City, State, Zip Code:_____________________________________________________________

Phone No:______________________________________________________________________

E-Mail:________________________________________________________________________

Method of Payment: Cheque Credit Card Visa MC American Express

Other Card Please Specify:_________________________________________________________

Credit Card No: _______________________ Exp. Date:_________________________________

Customer Signature:______________________________________________________________

Seller Signature:_________________________________________________________________

4 X 8 Brick Paver up to 3 Lines by 16 Characters per line. TOTAL €80

Important: Preferred County:____________________________

Please complete the form and brick details and forward with payment to…

Mr. John M. Cahill,

Ballybrittas, Bree, Enniscorthy, Co. Wexford, Ireland.

Tel: 053-9247656. Mobile: 087-6379708.

E-Mail:- weddcars@eircom.net.