Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Is the object under copyright? *

Yes

No

Unknown

Is yes, can the donor transfer copyright to the museum? *

Yes

No

Unknown

Not under copyright

Has the object been included in any publication? *

Yes

No

Unknown

Has the object been altered or repaired? *

Yes

No

Unknown