Museum Item Donation – Temporary Custody Form

This is to acknowledge receipt of items listed below by the St. Lucas Historical Society from:

Full Name:

Date:

Address:

City:

State:

Zip Code:

Work Phone Number:

Home Phone Number:

Fax Number:

Cell Phone Number:

Website:

Email:

The items listed below are left in the custody of the St. Lucas Historical Society to be considered as:

An unconditional donation. The Museum reserves the right to keep, lend, or otherwise dispose of the donated material

To be considered for acquisition

For identification. Does not constitute authentication, will not include appraisals. Museum reserves the right to photograph.

For other. Please specify:

Disposition if not accepted for accession:

Source will pick up

Please dispose or destroy

May be sold to benefit St. Lucas Historical Society

Items and Description:

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