Donation Form

North Carolina Preservation Consortium
Tax Identification Number: 58-1924603

Please print, complete, and mail this donation form with your check, payable to the North Carolina Preservation Consortium to:

North Carolina Preservation Consortium
Post Office Box 2651
Durham, NC 27715-2651

Thank you for supporting the preservation of our state's cultural, educational, and historical collections in archives, libraries, historic sites, museums, and record centers.

Circle Title: Mr. Ms. Mrs. Dr. Other ___________________

Please Print.

Name: ____________________________________________

Address: __________________________________________

City, State, & Zip Code: ______________________________

Telephone (day): ____________________________________

Email Address: ______________________________________

Given in ___ honor ___ memory of: ______________________________

Amount enclosed: $ ______________

Matching gift contact (if applicable):

Name: ____________________________________

Title: _____________________________________

Business or Institution: ____________________________________

Telephone: __________________________

Matching gift amount: $ ____________

 

 

 

 

 

 

 

last updated 6/6/05

copyright 2005 North Carolina Preservation Consortium