Buy-A-Brick Mail Order Form

Help build the future legacy of hope at The Connecticut Hospice. Your investment in the “Buy-a-Brick” program will help fulfill the goal of our new state-of-the-art hospital hospice. This is a tax-deductible contribution to The Connecticut Hospice, Inc. Display your name or the name of your church, your school, or your loved one.
 
$250.00per brick.
Tax Deductible 501(c)(3)
 

What do you want written on the brick?
- Bricks Measure 4x8 - 3 Lines Per Brick - 13 Characters Including Spaces
line 1:
line 2:
line 3:

Buyer Information
Please enter you information here: If paying by credit card, please be sure this matched the billing address of your credit card.
Name of buyer:
Street Address:
City:
 State:
Zip:

Do you want us to notify anyone of this gift?

The Connecticut Hospice will notify the family of your gift. Please enter the name and address of the family or person(s) you would like us to notify:
Name of person to notify:
Street Address:
City:
 State:
Zip:

Additional Donor Information (if relevant)

Please enter names and contact information for relevant parties IF:
1. If the donor is someone other than the credit card holder
2. There is more than one donor
3. You have any additional donor information you would like us to know

Payment Information: Pay by credit card or mail check

Type of Card: Visa Mastercard I am including check
Name on card:
credit card number:
expiration date:
 

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