WESTERN COUNTIES REGIONAL LIBRARY
CHARITABLE ASSOCIATION

Memorial Donation

Branch ____________________ Date  _____________________________

This donation to the Western Counties Regional Library Charitable Association
is being made in memory of
__________________________________________________________

An acknowledgement card should be sent to:
Name  ________________________ Amount of donation  _________________
Address ______________________ Do you want a tax receipt?   Yes ___ No  ___

______________________            (Tax receipts can be given for amounts of $10.00 and over.)
______________________  
Would you like us to purchase a special memorial book or other item?   Yes ___     No ___
If so, is there a format and/or type of material which would be especially appropriate?
___________________________________________________________________
___________________________________________________________________
A giftplate can be placed in the book.  Please give any special wording you would like used.
___________________________________________________________________
___________________________________________________________________
Name of donor     ___________________________________
Mailing address    ___________________________________
                            ___________________________________
                            ___________________________________

Thank You for your donation!
For librarian's use:  
Acknowledgment card sent ___________________  Letter to donor (date)__________
Item ordered (title)  ________________________________________________________
(date) ______________________
Item ready for branch (date)__________________________
July 2001
If you have any questions or comments please contact us at ansy@nsy.library.ns.ca