The Sister Dulce Foundation
(
Revised 10/19/09)
The Sister Dulce Foundation
CYPRESS SPRINGS MERCEDARIAN PRAYER CENTER
Brick Campaign
17560
George O’Neal Road, Baton Rouge, LA 70817 • 225-752-8480
•
email:
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INSTRUCTIONS:
•
Complete form and return with your payment to:
The Sister Dulce Foundation, 17560 George O’Neal Road, Baton Rouge, LA 70817
•
Make checks payable to
The Sister Dulce Foundation
.
Purchaser: _____________________________________________________________Date: ____________________
Address: _______________________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________________
Phone: ______________________________________
Email: _____________________________________
(
Area Code)
Number
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PAYMENT METHOD
:
___
Cash ___ Check
Donation: $100 per brick order
Credit Card: ___Visa ___Master Card ___ American Express Other: _____
(
if paying with credit card, please check one)
Credit Card Number: _____________________________________________________________ Exp Date: _________________
Name on Credit Card: _________________________________________________________________ *Code: ______________
*3
or 4 digit code found on credit card
I authorize the following amount to be charged to my credit card: $100
Signature: __________________________________________________________________ Date: ________________________
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ENGRAVING INFORMATION:
Brick size: 4x8x2 1/4"
Submit one order form and remittance of $100 per brick. If purchasing more than one brick, make copies of this form.
Inscription: 3 lines- 20 characters per line
(
includes spaces and punctuation)
.
The information you provide will go on the brick as shown on this form
.
Please check spelling carefully
.
Line 1: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(
20
Characters
) (
Please print
one letter/number per space provided including punctuation & spaces)
Line 2: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(
20
Characters
) (
Please print
one letter/number per space provided including punctuation & spaces)
Line 3: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(
20
Characters
) (
Please print
one letter/number per space provided including punctuation & spaces)
If you would like an acknowledgement certificate sent to someone, please provide the following information:
Name: _______________________________________________________
Address: _______________________________________________________
City:________________________________________State_________Zip Code: ____________________
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If you have any questions we can be reached by email at
or by calling the Ministry Center at
225-752-8480.
