LSUAA: Tile Registration Form

Purchaser's Contact Information:

Please Fill Out Every Field in the Form

First Name

Middle

Last Name

Address:

City:

State:

Zip:

Phone Number:

E-mail address:

CREDIT CARD INFORMATION

Credit Card #*

Exp Date* Ex. 06/07

Exact Name as it appears on the card:*

Choose Tile Size and Inscription:

$100 Tile Gift of $100 - 4" X 8" Tile
Inscription-14 characters per line, 2 lines maximum

Gift of $250 - 8" X 8" Tile
Inscription-17 characters per line, 2 lines maximum

Gift of $500 - 8" X 8" Tile
Inscription-20 characters per line, 3 lines maximum
(Memorial Tower logo included)

LSU Alumni Association reserves the right for copy approval/refusal.

Your order will be acknowledged.

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