Walkway of Champions

Personalized Brick order form
Donors may request up to three lines, 18 characters per line, to be engraved on each brick.  Please place one character - letter, punctuation mark (period, comma, hyphen, or space) or number- one per square.  Number of bricks in the project is limited.  Orders will be filled as space permits.  Please print the following and send as requested below.

Is this a:

______ Memorial gift

Name of purchaser________________________________________________
Address__________________________________________________________
City__________________________________State____ Zip________________
Primary e-mail_____________________________________________________
Second e-mail______________________________________________________
Daytime phone (____)__________________

Name and Address to send certificate and/or mini brick (if different from above)
__________________________________________________________________
__________________________________________________________________
City__________________________________State____ Zip________________

Brick 1    q Red     q White            q Mini

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Brick 2    q Red     q White            q Mini

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Brick 3    q Red     q White           q Mini

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_____Red bricks ordered @ $75 per brick        $______________
_____White bricks ordered @ $150 per brick  $______________
____ Mini bricks @ $15 per brick                       $______________
                                             TOTAL DUE            $______________

Please make checks payable to:  NC Agricultural Foundation
Credit Cards welcome!     please circle card type:
American Express    Discover    MC    VISA
Name on Card___________________________________________
Card number____________________________________________
Expiration Date__________________________________________
Signature________________________________________________

Mail form to:
CALS Alumni and Friends Society
Campus Box 7645
Raleigh, NC  27695-7645

Fax form to (credit cards only):
919-515-5274

Call your order in at:
919-515-7222
To order additional bricks, please print additional forms.