Southeastern Louisiana University

Number of bricks to be purchased: ($100.00 per brick)
Total Contribution: $ (ex. $100.00 for one brick, $200.00 for two bricks, etc.)
Personal Information:
Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
E-mail Address:
I prefer to pay with my:	VISA Master Card (select one)
Account Number:
Expiration Date:	Month: Year:
CVN:	(last 3 digits on back of card)
Today's Date:
Brick Message: You can put up to three lines of text on the brick. Each line must be 16 characters or less.