Citizens Library Memorial & honorary book Request

 Send to:  Memorial Dept.  55 South College Street  Washington, PA 15301

Minimum amount is $25.00 for an adult book and $15.00 for children's

 Amount of Memorial:__________            Amount Enclosed:__________

Name of Donor: ___________________ Phone Number:  __________

 Address of Donor:  __________________________

                                 __________________________

In Memory or in honor Of
(Name or name and occasion as it is to appear on the book plate)


 Presented By
(Name of the donor as it is to appear on the book plate)

 

Sent announcements of your donation to this name & address:

______________________________________

______________________________________

______________________________________

Suggested subjects: (books may not be available on all subjects) ______________
 

For Office Use
Received by:                                   Date:

Circle one:            Desk                    Phone                    Mail

Amount of Memorial:                         Amount Paid: