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Legacy Brick Order Form

Your Information

Name:
First Name*:
Last Name*:
Spouse First Name:
Spouse Last Name:

Address:
(should match where your credit card statement is mailed)
Street Address*:

City*:
State*:
Zip*:

Contact Info:
Phone Number*:
( ) -  
E-mail Address*:
Submission Options and Payment Amount
I am a (check all that apply)*: Current Parent
Parent of Alum
Alumnus/Alumna    Class of:
Grandparent         Grandchild's Name:
Supporter
Faculty/Staff

$107.50
4"x8" Legacy Brick
(cost includes FREE Minature Brick - Limited Time Only! Ends October 23rd)
LINE 1:
LINE 2:
LINE 3:

PLEASE NOTE:
There is a maximum of 20 characters per line.  
All lines will be centered. 
Spaces and punctuation count as characters. 

2"x4"Commemorative Miniature Brick (FREE WITH PURCHASE OF BRICK - Limited Time Only! Ends October 23rd)
LINE 1:

PLEASE NOTE:
There is a maximum of 20 characters per line.  
All lines will be centered. 
Spaces and punctuation count as characters. 

Shipping Information
Shipping Information is the same as Billing Information
      Required for Miniature Brick delivery.

Name:
First Name*:
Last Name*:

Address:
Street Address*:

City*:
State*:
Zip*:
Credit Card Information
Card Type*:
Card Number*:
Card Security Code*: (3 or 4 Digit Code - Learn More)
Name on Card*:
Expiration Date*: