Text is limited to name, major and class year, and may be edited to meet space requirements. A confirmation letter will be sent to you prior to engraving. No refunds or replacements will be given after the confirmation letter is signed. Engraved bricks are $125 each, and the donation is 100% tax deductible. (Copy this form for additonal brick orders).

First Name, Last Name

Major

Grad Year

Purchaser's Name



Address:_____________________________________________________________________

City:__________________________________State:___________ZIP:____________________

Day phone: ( ____ ) ___________________

FAX:( ____ ) ____________________

E-mail: ______________________________________________________________________

___ Check, please make check payable and mail to:

CSULB Alumni Association
1250 Bellflower Blvd.
Long Beach, CA 90840-0601


____Credit Card
____CSULB Alumni Assn. MasterCard ____VISA
____Other MasterCard ____AmEx


Account Number:

Exp Date: ___________________ Signature:___________________________________

Phone: 562/985-7014, and fax orders 562/985-5488 accepted with credit card number.