Name_________________________________________________________________________

Address:_______________________________________________________________________

City:___________________________________________________________________________

State & Zip:_____________________________________________________________________

E-Mail Address:__________________________________________________________________

Type of Entry:
___story about how Brian has influenced/helped you
___thank-you to Brian
___picture
___poem
___letter to Brian
___other (please specify:____________________________________________________________)

Number of Pages Sent:__________________________________________________________

Total Amount ($5/page):__________________________________________________________

Date Sent:_____________________________________________________________________