Brick Order Form - DeMolay International

Member ID
First Name*
Last Name*
Address*
City*
State*
Zip Code*
Phone
Email*
Brick Choices*
- 4X8 Brick - $200
- 4X8 Brick + Full Size Replica - $250
- 8X8 Brick - $1,000
- 8X8 Brick + Mini Replica - $1,050
Add a logo*
- DeMolay Emblem - $25
- Scottish Rite - $25
- York Rite - $25
- Shriners Emblem - $25
- Military Logo - $25
- Square and Compass - $25
- None
If a logo is chosen your top three lines will be limited to 8 characters. If zero characters are placed in the first 3 lines the logo will be centered.
Engraving Line 1
Engraving Line 2
Engraving Line 3
Engraving Line 4
Engraving Line 5
Engraving Line 6
Brick Text: (All text will automatically be centered left to right, and top to bottom. Type your characters exactly as you would like to see them on the brick. Spaces are recognized as a character. This includes upper and lower case, or any combination of the two.)
Who is purchasing this brick*
- Individual
- Organization
Name of the organization:*
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Total
$0.00
Please note that replica bricks will not be shipped until late spring 2019