Year/Major:

Street:                           City:

State:                    Zip Code:

Telephone:                   FAX:

E-mail:

Brick/Miniature Trojan Information

Select the contribution you plan on making:

For Brick $100 $150 $200 $250 $300

For Miniature Statue

The following information relates to the brick:

The 3.5" X 7.5" X 1" paying brick can be inscribed with up to 3 lines with twenty characters per line.  Each brick will be set permanently and each contributor will receive a map detailing the exact location of their personalized brick.  Fill in the following fields with the name and/or inscription as they should appear on the brick.  You must count spaces as characters.

Line 1:

Line 2:

Line 3:

Form Submission

After you submit this form you will be contacted by the Alumni/Foundation Office to make arrangements for payment.  PLease ensure that the information on the form is correct.  All information will be kept strictly confidential.