C-SC Plaza Brick Order Form


Mark your place on the Culver-Stockton Plaza with a personalized brick.
This Gift to C-SC is from
Donor:  
Preferred Phone Number:      
 
BRICK INFORMATION
* Number of Bricks:
4x8 Standard Bricks ($100 each):
8x8 Limestone Bricks ($200 each):
12x12 Limestone Bricks ($350 each):
Total Donation:$
* BRICK INSCRIPTIONS
4x8 Standard Brick ($100):
Please type your inscription, using up to 3 lines of up to 14 characters/spaces per line.
Line 1:
Line 2:
Line 3:
8x8 Limestone Brick ($200):
Please type your inscription, using up to 6 lines of up to 14 characters/spaces per line.
Line 1:
Line 2:
Line 3:
Line 4:
Line 5:
Line 6:
12x12 Limestone Brick ($350):
Please type your inscription, using up to 6 lines of up to 17 characters/spaces per line.
Line 1:
Line 2:
Line 3:
Line 4:
Line 5:
Line 6:
Optional Information
Confirmation E-mail:   
Enter your preferred email address in the space above to receive a confirmation of this transaction. Please check to ensure your email address is accurate.