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4X8 BRICK ON-LINE ORDER FORM
$50 Donation
NAME:
EMAIL:
ADDRESS:
CITY, STATE, ZIP:
,
PHONE::
Brick Example
INFORMATION FOR BRICKS: $50 Donaton=Four lines maximum, 18 characters per line with spaces, periods, and all other characters counted when figuring the total number of characters per line. Each blank will not allow you to type in more than 18 characters.
First Line, 18 characters:
Second Line, 18 characters
Third Line, 18 characters
Fourth Line, 18 characters
CERTIFICATE - $10 Donation
Certificate total: $
Mail Certificate to:
Address:
City, State, Zip:
Total Amount Donated: $
Below is a "Submit" button which will send this form with all the info and then you will go to the shopping cart whjch will enable you to pay securely on-line through PayPal using all major credit cards and electronic checks. You will receive a receipt for payment. Please click the button and a window will open where you can select your item(s) and pay for them,
Make checks payable to Chapter 391, Vietnam Veterans of America
