Join Brick Program

Join Now and secure your support for this important kaupapa. Bricks will not be issued until full payment has been received by MaraeMelbourne.

Brick Holder Information

Name
Address
City
State/Province
Postcode
Country
Phone (H) (including country & area code)
Phone (M) (including country & area code)
Date of Birth (dd/mm/yyyy)
Email
Sponsor Name (Leave blank if none)
Plaque Inscription (30 characters max)
Tribe/Affiliation (iwi/hapu - if none or unknown leave blank)
Payment Option:	I will make a one off $100.00 paymentI will make instalments of $10 over 10 monthsI will make instalments of $10 over 10 weeks
Payment Method: (please do not provide credit card or other payment details via this form. You will be contacted separately.)	Direct Bank TransferCheque/Money OrderCredit Card
	I am 18 years of age or older
	I have read, understood & accept the Terms & Conditions.

Read full Terms & Conditions here