STAR PLAZA DONATION FORM
Date:
Fill out the donation form below with your name, address, daytime and evening phone number, desired inscription and
whether you would also like to be recognized with a personal replica of your star. Please mail or fax your donation form to:
STAPLES Center Foundation
Attn: Jennifer Lynch
800 W. Olympic Blvd.
Los Angeles, CA 90015
FAX Number: (213) 763-7710
8" X 8" Porcelain Star(s)
Porcelain Replica(s)
_____ X $175 = $ ___________
_____ X $50 = $ ___________
Total: $ ___________
8" X 8" Lakers Gold Star(s)* _____ X $300 = $ ___________
_____ X $50 = $ ___________
Lakers Gold Replica(s)*
Total: $ ___________
12" X 12" Granite Star(s)
Granite Replica(s)
_____ X $3,050 = $ ___________
_____ X $75 = $ ___________
Total: $ ___________
Grand Total: $ ___________
My Star should be inscribed as follows:
Directions: Please use one letter/symbol/space per box. Use the white spaces to write messages for the 8" X 8" porcelain star. Additional shaded spaces are
for the 12" X 12" granite stars messages only. Please use only those letters and symbols which appear on a typewriter keyboard. If you are ordering more
than one star, please attach additional inscriptions to this order form. Inscriptions are subject to approval.
Method of payment:
Check or money order (payable to STAPLES Center Foundation)
Credit Card (select one):
VISA
MASTERCARD
AMERICAN EXPRESS
Card Number: ___________________________________________________
Exp. Date: ______________
Signature: ___________________________________________________________________________________________
Name: ______________________________________________________________________________________________
Address: ____________________________________________________________________________________________
City: __________________________________ State: _______
Zip: ___________
Phone Number: (daytime)___________________________
(evening) __________________________________
(If you are ordering a replica, please make sure your address is not a P.O. Box as your replica will be shipped to you via UPS)
* Limited Edition Lakers NBA Championship Porcelain Star. For more information, please call (213) 742-7166.