Brick/Paver Form

Walk of Honor

Brick/Paver Information

Amount

For purchases of more than three bricks, please call (601) 928-6344

Each brick purchased may be inscribed with three lines of text, 13 characters per line.

Brick 1 - Line 1

Brick 1 - Line 2

Brick 1 - Line 3

Brick 2 - Line 1

Brick 2 - Line 2

Brick 2 - Line 3

Brick 3 - Line 1

Brick 3 - Line 2

Brick 3 - Line 3

I would like to dedicate this donation

Contact Information

First Name

Last Name

Company Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work 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 $50.00 to go to MGCCC Foundation and I will donate $51.50.No. I will donate $50.00 and MGCCC Foundation will cover the processing costs.

Payment Information

Payment Options

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the total of all items selected. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.