Coromandel Club Buy-a-Brick Form
Please make sure to fill in the required fields and submit this form to complete your order.
Your Name
*
First Name
Last Name
E-mail
*
example@example.com
Contact Number
Which Brick do you want?
*
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( X )
Large Brick
Comes with a short 50 character limit message.
$
200.00
NZD
Medium Brick
$
100.00
NZD
Small Brick
$
25.00
NZD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Name on Brick
*
First Name
Last Name
Brick Message (Only applicable for Large Bricks)
50 Character limit
0/50
Submit
Should be Empty: