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
Format: (000) 000-0000.
Which Brick do you want?
*
prev
next
( X )
Large Brick
Comes with a short 50 character limit message.
$200.00 NZD
$
200.00
NZD
Medium Brick
$100.00 NZD
$
100.00
NZD
Small Brick
$25.00 NZD
$
25.00
NZD
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Name on Brick
*
First Name
Last Name
Brick Message (Only applicable for Large Bricks)
50 Character limit
0/50
Submit
Should be Empty: