Date __ __ __
Initials ____ __ _
Cannon County Library System
$ _________ 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: