I am/We are the owner/owners of the object/s described in the schedule below and I/We hereby donate such object/s to the Irish Cultural and Historical Society of the Mohawk Valley (dba The Irish Cultural Center of the Mohawk Valley (ICCMV)).
The object/s donated is/are not encumbered in any way whatsoever.
I/We acknowledge that the donation as such will result in the ICCMV becoming the owner at law of the said object/s, with all rights and powers to do with the said object/s as it sees fit. This may include disposal, which may or may not include efforts to return the object/s to the donor or the donor’s heirs.
I/We consent to the ICCMV retaining the personal information disclosed below.
I/We give permission to the above-named museum to use the information I/We have provided about the history of the object/s for future museum purposes, including research, public research access, displays and publications.
Restrictions on public access to information provided:
Name:
Address:
Email:
Tel:
What artifacts or library materials are you offering to donate to the Irish Cultural Center of the Mohawk Valley? Please describe the artifact as specifically as possible. Include measurements, weight, color, etc:
What is the history significance of your materials and how do they relate to Irish culture and/or history? (Date made, previous owners, usage history, etc.):
Signature/s: Date:
