Submit Printed YBR Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required THIS FORM IS FOR USE BY VILLAGERS THEATRE STAFF, TO KEY IN PRINTED YELLOW BRICK ROAD FORMS. YOU MUST USE THE CREDIT CARD TERMINALS IN THE BOX OFFICE, TO PROCESS ANY CREDIT CARD CHARGES. PATRON/BUYER'S DETAILS: First Name * Last Name * Phone Email Street Address 1 Street Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code A 3"x8" brick can have from 1 to 3 lines of text (inscriptions), 15 characters wide. An 18"x18" brick can have from 1 to 16 lines of text, 30 characters wide. Type in the text that the patron specified. If you cannot clearly read what the patron wrote on their form, first call them to confirm - before proceeding!!! Please make sure you type EXACTLY what the patron wants engraved in their brick! Be smart about checking for spelling. If there is a name in the inscription, does any of it match the first/last name they specified on the form? Does the spelling of a word look off? You can always check www.dictionary.com. Call the patron to verify any possible issues! Inscription 3x8 Line 1 Inscription 3x8 Line 2 Inscription 3x8 Line 3 Inscription 18x18 All Lines Below Brick Price Additional Donation Total Donation Check Number (if paying by check) Check Date (if paying by check) Transaction ID (if paying by Credit Card) Transaction Date (if paying by Credit Card) Approval Code (if paying by Credit Card) After clicking Confirm Order below, please wait till processing is complete. Please do NOT hit your browser's BACK button or close your web browser until prompted to do so, or your order may be lost.
