DONOR ACKNOWLEDGEMENT & NAME-USE CONSENT Form Code: HSW-F29
HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM
DONOR ACKNOWLEDGEMENT & NAME-USE CONSENT
Form Code: HSW-F29
Date: ____ / ____ / ______
1. DONOR DETAILS
1.1 Donor Name: ________________________________
1.2 Address (optional):
___________________________________________
___________________________________________
1.3 Phone / Email (optional):
___________________________________________
2. DONATION SUMMARY
2.1 Type of Donation:
[ ] Cash [ ] Object / equipment
[ ] Relic [ ] Service / other
2.2 Short Description:
___________________________________________
___________________________________________
3. HOW DONOR WISHES TO BE RECOGNISED
(Tick all that apply)
[ ] Name on small plaque
[ ] Name in annual report
[ ] Thank-you letter only
[ ] Anonymous (no public recognition)
[ ] Other: __________________________________
4. MEDIA AND PHOTO CONSENT
4.1 I agree / do not agree that my name and/or photo
may be used in:
[ ] Museum website
[ ] Printed reports
[ ] Social media
[ ] Press / news
[ ] I do not agree to name or photo use
4.2 Conditions (if any):
___________________________________________
5. SIGNATURES
Donor:
Name: ________________________________________
Signature: __________________ Date: ____/____/____
Museum Representative:
Name: ________________________________________
Role: ________________________________________
Signature: __________________ Date: ____/____/____