Legacy Brick Order Form

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Date

Today’s Date

Membership #

Name*

First Last

Phone*

Email*

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Price per legacy brick

Price:

Price per legacy brick is $150.00 plus tax.

Brick Inscription: (3 lines maximum, 20 spaces per line)*

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Convenience Fee

Price: $0.00

Total

Pay by check

Member paid by check

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Legacy Brick Order Form*

Must be paid at time of signup, payment is non-refundable.

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