Engraved Brick Order Form

The cost of each brick is $100. Please make check payable to Lake Aurora Christian Camp.
Print the following form and mail or fax to 863.696.1062

First Name:________________________________________________________

Last Name:________________________________________________________

Mailing Address:____________________________________________________
City:________________________________ ST______ Zip__________________

Phone(s):_______________________    ________________________________
e-mail:____________________________________________________________

Please circle Pymt method:    Cash/Check           
Credit Card:    Mastercard               Visa            
Exp. Date:_________________    Security Code:(3 digits) ______________

Card #:_____________________________________________________________

Holder's Signature:___________________________________________________
Holder's Printed Name:_______________________________________________

Please PRINT or TYPE exactly as you want your brick to be printed.
You may use up to 14 characters per line with a maximum of 3 lines.
Spaces count as a character.

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r   I am requesting a "gift certificate" to present to the one being honored.