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Brick by Brick Online Order Form

Brick by brick, we will build this university with your help. Donate $300 for a personalized
brick, and see your name built into George Wythe University.

First Name:*
Last Name:*
Street Address:*
City:*
State:*
Zip:*
Phone:*
E-mail:*
Confirm E-mail:*

Inscription:

20 characters per line. (15 available on line three)
Spaces are considered characters in a line.
Text will be capitalized and automatically centered.
All standard letters, numbers, and punctuation are acceptable.
All messages are subject to approval.

Brick inscription line 1:	(includes spacing and punctuation)
Brick inscription line 2:	(includes spacing and punctuation)
Brick inscription line 3:	2009 (includes spacing and punctuation)
Number of Bricks with this inscription:

Add Another Brick Inscription

Please give credit to the following individual or group contest participant
Contest Participant Name:*

Number of Bricks	Total Donation Amount
1	$300

Payment Method:*

Credit Card Checking Account (ACH)

Credit Card Info
Card Type:*
Card Number:*
Expiration Date:*
Card Code:*	? This is the CVV, CVC or CID. The three- or four-digit number on the back of a credit card (on front for American Express).
Name on Card:*

Checking Account (ACH) Debit Authorization
Bank Name:*
Bank Location:*
9-Digit Bank RTN#:*
Primary Account #:*

Billing Address
Same as above:	Yes No


	* Required Fields

For questions, please contact Laney Cheney, Resource Development Vice President
GWU Department of Resource Development
970 South Sage Drive
Cedar City, UT 84720
Phone: (435) 586-6570 ext 150
Fax: (435) 586-3697

All Proceeds from GWU Brick By Brick benefit the Monticello Campus construction. GWU is a
501(c)3 organization, so all contributions are 100% tax deductible. Thank you for your support of George Wythe University.

Get Your Degree From Home

Brick by Brick Online Order Form