Copiah-Jefferson Regional Library

Patron Donation Form

Patron Name: ________________________________________

Receiving Branch:   CS    GE    HA    FA    WE

Monetary donation:    $____________  (Do not use to set value of material donation)

Material donation:

Employee Signature:   ___________________________________                            

                  Date:            ___________________

In regards to this specific donation, does CJRL have your permission to include your name when publicly recognizing library donations?  Gifts of money will be noted as ‘a gift’ and will not indicate a particular amount.

_____YES        ____NO                        

Patron’s Signature:   __________________________________________          

                Date:           _____________________