Process Payment for Commemorative Brick ($100 per brick) Your name* Address Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* I would like to buy bricks*Please enter a number from 1 to 5.Each brick can have up to 3 lines per brick and no more than 15 characters per line including spacesEach line will be centered on the brick unless you include special comments belowThere is an additional $10 fee for any character other than a letter, number, or spaceOnly one fee per brick, not per character!Special characters include: ! @ # $ % ^ & * ( ) + = – _ < > ? / ~ " ' : ;Please note there is an additional $10 charge for each special character that is not a letter, number or space.HiddenThe box for special character charge is required for each brick purchasedOnly one fee per brick, not per character! Brick Line 115 characters including spaces Brick 1 Line 215 characters including spaces Brick 1 Line 315 characters including spaces Heritage Frederick Brick 1 Cost* Price: Brick 1 Special Character Fee* Yes No Brick 2 Line 1 Brick 2 Line 2 Brick 2 Line 3 Heritage Frederick Brick 2 Cost* Price: Brick 2 Special Character Fee* Yes No Brick 3 Line 1 Brick 3 Line 2 Brick 3 Line 3 Heritage Frederick Brick 3 Cost* Price: Brick 3 Special Character Fee* Yes No Brick 4 Line 1 Brick 4 line 2 Brick 4 Line 3 Heritage Frederick Brick 4 Cost* Price: Brick 4 Special Character Fee* Yes No Brick 5 Line 1 Brick 5 line 2 Brick 5 Line 3 Heritage Frederick Brick 5 Cost* Price: Brick 5 Special Character Fee* Yes No Additional comments or requestsMaximum 150 charactersTotal $0.00 The Special Character Fee button MUST be checked for EACH brick ordered or the order will not go through.You must click the SUBMIT button after filling in your credit card information.Credit Card Cardholder Name Card Details PhoneThis field is for validation purposes and should be left unchanged.
