The University of Mississippi Athletics
UMAA Foundation Brick Campaign for the All-American Plaza
9/25/2006 | Athletics
INSTRUCTIONS
If you wish to purchase more than one brick, please copy this form for each additional order. Inscriptions can be up to 14 characters on three separate lines and will be centered. All letters will be uppercase and in a standard style and font. All inscriptions will be subject to approval by the UMAA Foundation.
Name: ________________________ Phone (home): ________________________
Address: ________________________ Phone (work): ________________________
City/State/Zip: ________________________ Email: ________________________
South End Zone Bricks: 4 x 8 $100 each Quantity ________ = $________
Replica Bricks: 4 x 8 $50 each Quantity ________ = $________
*** A South End Zone Brick must be purchased before purchasing a Replica Brick
Indoor Practice Facility: I wish to donate $______________ to the Indoor Practice Facility.
I want to set up a payment schedule to complete this pledge:
Monthly: _____ payments of $__________
Annually: _____ payments of $__________
Inscription:
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
__ Check enclosed
__ MasterCard
__ Visa
Name on card: ______________________________
Card number: ______________________________
Expiration date: ______________________________
Signature: ______________________________
TOTAL AMOUNT DUE: _______________________
Please print and mail this form to: UMAA Foundation, PO Box 355, University, MS 38677