Date __ __ __

                                                                                                                                                 Initials ____ __ _

Cannon County Library System

Donation

$  _________ Memorial

$  ______________Gift from Author

$ ____________Adams Memorial Library Building Fund

Donation for _____Adams Memorial _____Auburntown _____Genealogy

In Memory of ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ _________

Name as it will appear on book plate.

Mailing Address __________________________________________________________

Address where notice of donation is to be sent.

____________________________________________________________

____________________________________________________________

Name of Donor (s) ____________________________________________________________

Name (s) as they will be recorded on book plaque.

Address & telephone ____________________________________________________________

Number of donor (s)

____________________________________________________________

____________________________________________________________

____________________________________________________________

Title selection will be at the discretion of the Director following the collection development plan.

A bookplate will be placed in the purchased book stating the name of both the honored and donor.

A card will be sent as notification to either the funeral home or person designated by the donor (s).

May we mention your gift in press releases? Yes _____ No _____

Except in rare instances we do not accept pre-purchased books by the donor for memorial gifts.

This form constitutes the entire understanding of the agreement. Memorial Card Sent _______

Thank You Sent ___________

Items (s) Purchased: