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First Name*  
Last Name*  
Street Address*  
City*  
State*
Zip*     
Email*     
Phone*  
Birthdate** (mm/dd/yyyy) / /
 *Your Birthdate is used to identify your previous donations and make sure they are attributed correctly.
 
4x8 Brick
8x8 Brick



Your wording is all uppercase, centered on the line.
13 Characters Per Line Max (39 Total)



Total: $200