POTENTIAL DONATION FORM

Your Name *

Your Address *

Your Phone Number *

Your E-mail *

Are you the legal owner of the piece being offered? *

Donor Information, if different from yours:

Name

Address

Phone

To be considered for acquisition by the Grout Museum District.

For Other. Please specify

Permission is granted to add this donation to the disposable collections for Exhibit, Education or Public Programming.

Grout Museum District has permission to dispose of all pieces not wanted for Collections.

May be sold to benefit the Grout Museum District.

Piece(s) Description *

Who Used Piece(s): *

When were they used: *

Where were they used: *

Additional Information: