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
