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All required fields are marked with a *

* (Please check one of the radio buttons)
Yes!
I want to be a permanent part of Queens College history. Here is my contribution and a order for a regular brick. ($250 per brick. 3 lines, Maximum 14 characters per line, including spaces.)
 Yes!
I want to be a permanent part of Queens College history.  Here is my contribution and a order for an 8" x 8" brick. ($500 per brick. 6 lines, Maximum 14 characters per line, including spaces.)

* First Name:    
M.I.:    
* Last Name:    
    
* Street Address:    
Apt:
* City:    
* State:    
* Zip:    
* Home Telephone:    
Business Telephone:
* Email Address:    

*(Please check one of the radio buttons)
     This is a surprise gift. DO NOT send acknowledgement letter.
      Please send notification of this gift to:

 
First Name:    
M.I.:    
Last Name:    
    
Street Address:    
Apt:
City:    
State:    
Zip:    

* Please type the information exactly as you would like it to appear.
Maximum 14 characters per line, including spaces.

  Sample
IN MEMORY OF (IN HONOR OF)
JOHN DOE
CLASS OF 1940

For additional bricks, please type the information below.
* Please type the information exactly as you would like it to appear.
Maximum 14 characters per line, including spaces.

  Sample
IN MEMORY OF (IN HONOR OF)
JOHN DOE
CLASS OF 1940

For additional bricks, please type the information below.

This brick is a gift:
*(Please check one of the radio buttons)
 Alumni         Parent         Faculty/Staff         Friend

If you would like your brick placed next to a friend's, your order must be placed together.


Please check the information above and verify that all is correct. Once you have done so, please click the Continue button below to enter your order., or click clear form to clear the form's contents.