Legacy Lane Order Form.

Please include engraving request in the box below.
Maximum 16 characters per line, 3 lines for each brick ordered. Spaces and punctuation are included as characters. Text will be capitalized and center justified on the brick. 

Donation Information
Amount:	One personalized brick $ 100.00 $     *
Designation:	The Fund for UT Dallas (unrestricted) Other
Other	*
Additional Information
Frequency:	Weekly Monthly Quarterly Annually On:   Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting:    Ending:   Ending:
Anonymous:	I prefer to make this donation anonymously
Comments:
Legacy Line 1:		*
Legacy Line 2:		*
Legacy Line 3:		*
Place my brick with others in the class of:		*
Billing Information
Title:	Dr. Mr. Mrs. Ms. Mx. Miss Admiral Ambassador And Friends Assistant Professor Associate Professor Bishop Brigadier General Brother Cantor Captain Chairman Chairwoman Chancellor Chief Colonel Commander Commissioner Comptroller Congressman Congresswoman Councilman Councilwoman Dean Deputy Drs. Father General Governor Judge Justice Lieutenant Lieutenant Colonel Lieutenant Commander Lieutenant General Lieutenant Governor Madam Major Major General Master Sergeant Mayor Monsieurs Monsignor Mother Officer Pastor President Professor Rabbi Rear Admiral Regent Representative Retired Brigadier General Retired Colonel Retired Reverend Reverend Second Lieutenant Secretary Senator Sergeant Sheriff Sir Sir/Madam Sister Speaker Student Regent Superintendent The Children of The Estate of The Family of The Father of The Honorable The Mother of The Reverend Trustee Vice Chairman
First name:
Last name:		*
Country:	United States Albania Arabian Gulf Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Beijing Belgium Belize Bermuda Bolivia Botswana Brazil Camaroon Cambodia Canada Chad Chile China Columbia Costa Rica Croatia Cyprus Czech Republic Denmark Ecuador Egypt El Salvador England Ethiopia Fiji Finland France Georgia Germany Greece Guatemala Guinea Guyana Haiti Holland Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kenya Korea Kuwait Kyrgyzstan Lebanon Lithuania London Malaysia Maldives Mexico Mongolia Morocco Mumbai Myanmar Namibia Nepal Netherlands New Guinea New Zealand Nicaragua Niger Nigeria Norway Nova Scotia Oman Pakistan Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Rep. of Korea Rep. of South Africa Republic of Belarus Romania Russia Rwanda Saudi Arabia Scotland Seoul Sierra Leone Singapore Slovakia South Africa South Korea Spain Sri Lanka Sudan Sweden Switzerland Taipei Taiwan Taiwan, R.O.C. Tajikistan Tankania Tanzania Tanzania, United Republic of Thailand The Netherlands The Philippines Togo Tokyo Trinidad and Tobago Tunisia Turkey Turkmenistan Uganda Ukraine Ulhasnagar United Arab Emirates United Kingdom US Virgin Islands Uzbekistan Venezuela Vietnam Yemen Yugosalvia Zambia Zimbabwe	*
Address lines:		*
City:		*
State:	<Please Select> Que Sao TX Gua AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VA WA WV WI WY AA AE AP AS GU PR VI AB BC CZ FM Ont Kar MB MH NB NL MP NT NS NU ON PW PE QC Wes SK YT Khy Riy Guj And Tel Mah Utt Mad Raj We1 Tam Jam Odi Har Pun Tri Chh Sha Lag NCT Sic Est New Mak Amm Lim Gu1 Sh1 Bei Zhe Jia Heb Anh Hen He1 Atl Hes Gre Ass Ut1 Bih Ker Ut2 Pud Del Teh Far Gil Sem Isf Maz Lom Abr Gye Nor Gy1 No1 Kau Chi Ond Kwa Sin He2 Val Hai No2 We2 Jha Pu1 Seo Jel Gy2 No3 Alb Jeo Hun Jar Ra1 Osa Imo Ash Fuj Giz Si1 Riv Oyo FCT The Him Sa1 Al- Agr Goa Gu2 Ale Eas Mec Ist Bad Hub Ta1 Ham Lua Bat Cen Mar Mus Udi Uva Yun Tok Bog Laz Sou Uus Yaz Ea1 Ank No4 Beq Lu1 Ana Ben Man Sto Bav Tia Pah Jil	*
ZIP:		*
Phone:
Email:		*
Payment Information
Cardholder's Name:		*
Credit Card Number:		*
Card Type:	Visa American Express Discover MasterCard	*
Card Expiration:	01 02 03 04 05 06 07 08 09 10 11 12  / 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043	*
Card Security Code:		*
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Tribute Information
Type:	In Honor of In Memory of	*
Name:		*
First name:
Last name:		*
	Mail a letter on my behalf	*