The Baltimore Station

Bed & Bricks – Making it Home!<= o:p>

Final push for = The Baltimore Station=

First = /Last Name ______________________________________________

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Address _________ __________________________= _________________

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City/S= tate/Zip ________________________________________________

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Home P= hone ____________________ Cell Phone ___________________

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Email ________________________________

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Payment Information:

  Make check payable to The Bal= timore Station

Credit= Card:     <= !--[if gte mso 9]> FFFFFFFF650000001400060043006800650063006B003300000000000000000000= 000000000000000000000000000000   Visa    <= !--[if gte mso 9]> FFFFFFFF650000001400060043006800650063006B003200000000000000000000= 000000000000000000000000000000   MasterCard      <= !--[if gte mso 9]> FFFFFFFF650000001400060043006800650063006B003100000000000000000000= 000000000000000000000000000000   American Express <= /span>

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Name on Card: _____________________________________________

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Card #: ______________________________ Exp. Date: <= !--[if gte mso 9]> FFFFFFFF650000001400060043006800650063006B003500000000000000000000= 000000000000000000000000000000 /= <= !--[if gte mso 9]> FFFFFFFF650000001400060043006800650063006B003700000000000000000000= 000000000000000000000000000000    Verification Code: <= !--[if gte mso 9]> FFFFFFFF650000001400060043006800650063006B003900000000000000000000= 000000000000000000000000000000 =

▪ Please fill in the fields EXACTLY as you would like to see your brick(s) or plaque(s). Leave a space between names, and before and after "&".

▪ Each space counts as a character. Omit punctuation marks. Orders received together will be laid together; brick location will be determi= ned by architectural design.

▪ TBS reserves the right for copy approval/refusal. Special guidelines: If line and space permit:&= nbsp; (a) any brick or plaque may include "In Memory of" or "In Honor of" <= span style=3D'mso-spacerun:yes'> (b) affiliation allowed (group,= club, military, honors, social).

$150 brick, Small Brick=

Two lines maximum / 14 characters per line

$500 brick, Large Brick

Three lines maximum / 17 characters per line

$1000 bed and wardrobe, Plaque

From 1 – 3 lines maximum / up to 75 characters per line

Please return completed form to: Susan Pompa, Director of Development, The Baltimore Station,= 140 W. West Street, Baltimore, MD 21= 230, or email: spompa@baltimorest= ation.org, or fax to 410-752-4123. Call 410-752-4454 ext. 102 for more information.