BY DALE CARRUTHERS 
ORIGINAL PAINTINGS   PRINTS OF PAINTINGS
CUSTOM FRAMING   GIFTWARE
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Charitable Donation Application Form

Please print, complete and return by fax to (506) 450-4232

Date: _____________

Organization: _______________________________________________

Type of Services; ____________________________________________

Coverage area: _____________________________________________

Contact Person(s): ___________________________________________

Street Address: _____________________________________________

City/ Province; ______________________________________________

Country; _______________________________________

Postal/ Zip Code: _____________________

Fax # with area code: ________________    Tel # __________________

E-mail address: ______________________________

Product requested: Loose print Y/N?_____
Framed Print at cost plus: Y/N?_____
Commissioning Proposal: Y/N?_____

Please provide us an offical charitable receipt or confirmation letter on your corporate letterhead with the indicated value of the donation.
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     Birch Cres. Gallery, 1599 Woodstock Road, Fredericton, New Brunswick, Canada, E3C 1P2
     Phone (506) 450-4233                   www.dalecarruthersart.ca                   Fax (506) 450-4232



All Images are Copyright Dale Carruthers