Brick/Paver Form

Buy a Brick to Build a Foundation for Lifest

Select Your Brick Size

Please enter the message you would like on your brick. You do not need to use every line. Max 20 characters per line.

Line 1

Line 2

Line 3

Line 4 - For 8 x 8 Bricks Only

Line 5 - For 8 x 8 Bricks Only

Line 6 - For 8 x 8 Bricks Only

Contact Information

First Name

Last Name

Company Name

Address

City

State/Province

Zip/Postal Code

Primary Phone

Help Us Cover Costs

Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.

Yes! I want $100.00 to go to Life Promotions and I will donate $103.00.No. I will donate $100.00 and Life Promotions will cover the processing costs.

Payment Information

Payment Options

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.