DATE:_________________________

GIFT/BOOKPLATE INFORMATION FORM

Select One:

IN APPRECIATION OF THE PUBLIC LIBRARY

IN HONOR OF A BIRTHDAY

IN HONOR OF A WEDDING (OR WEDDING ANNIVERSARY)

IN MEMORY OF: ____________________________________________________

OTHER:_____________________________________________________________

Subject suggestion for the book:_________________________________________

PLEASE NOTIFY: Name ____________________________________________

Street Address ____________________________________________

City, State, Zip ____________________________________________

Relationship to deceased ____________________________________________

PLEASE NOTIFY: Name ____________________________________________

Street Address ____________________________________________

City, State, Zip ____________________________________________

Relationship to honoree ____________________________________________

PLEASE NOTIFY: Name ___________________________________________

Street Address ____________________________________________

City, State, Zip ____________________________________________

DONOR’S NAME __________________________________________________

Street Address ____________________________________________

City, State, Zip ____________________________________________

Phone No. ____________________________________________

AMOUNT OF GIFT: $ ______________________