SOUTHWEST
TENNESSEE
COMMUNITY COLLEGE
SOUTHWEST WALK OF HONOR
COMMEMORATIVE BRICK RESERVATION FORM
Your Information
Please complete and mail this form to:
Name
Southwest Commemorative Brick Program
ATTN: Chris Owens
5983 Macon Cove
Memphis, TN 38134
OR
Fax it to (901) 333-4671
Address
ZIP
State
City
Day Telephone
Evening Telephone
E-mail Address
4" X 8" brick: $100
8" x 8" brick: $250
Please use my donation for:
0 Alumni Scholarship
0 General Scholarship
Please install my paver at the following location:
0 Macon Cove Campus
0 Union Avenue Campus
0 Nursing Facility
0 Unrestricted Fund
0 Maxine A. Smith Center
Method of Payment
Check or money order (made payable to the Southwest Foundation)
Payroll deduction (Southwest employees only)
Credit card: circle one
Card #
Visa
MasterCard
Expiration Date
Name as it appears on the card
Signature
First line (20 characters maximum)
Second line (20 characters maximum)
Third line (20 characters maximum)
Fourth line (20 characters maximum)
Fifth line (20 characters maximum)
Sixth line (20 characters maximum)
Southwest
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Tennessee Community College, a Tennessee Board of Regents institution, is an affirmative action/equal
opportunity college. 0110905 REV 10019