By completing and submitting the below form, you are agreeing to have a representative from Diabetes Canada contact you in order to process your payment for the purchase of a brick for Banting House National Historic Site of Canada.

Full Name:

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* 1. Full Name:

Address:

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* 2. Address:

Phone number:

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* 3. Phone number:

Email address:

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* 4. Email address:

Type of brick (select one):

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* 5. Type of brick (select one):

Individual:
9x6: 4 lines, 16 characters per line (incl. spaces), 64 characters total
9x9: 7 lines, 16 characters per line (incl. spaces), 112 characters total

Service Club:
9x9: 7 lines, 16 characters per line (incl. spaces), 112 characters total

Corporate:
12x8: 5 lines, 20 characters per line (incl. spaces), 100 characters total
Brick messaging (see guidelines above):

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* 6. Brick messaging (see guidelines above):

T