CONTACT PERSON (Person Responsible for Print & Paperwork)

CHARITY PRINT COLLECTION
DONATION RECAP FORM

P. Buckley Moss Society

74 Poplar Grove Lane
Mathews, VA 23109 Ph: (800) 430-1320
Ph: (804) 725-7378 Fax: (804) 725-3040
Email: / Form #
2 / BOX FOR OFFICE USE

Return no later than 2 weeks after event.

Failure to comply may have an impact on future requests.
CONTACT PERSON (Person responsible for print & paperwork) / EMAIL

ORGANIZATION NAME

WORK PHONE

( )
ADDRESS /

HOME PHONE

( )
CITY / STATE / ZIP /

FAX

( )
Benefiting Organization
ORGANIZATION TO RECEIVE FUNDS
HOW FUNDS WILL BE USED (indicate specific programs)
Fundraising Event
EVENT NAME (if applicable) / TYPE OF EVENT
___ Raffle ___ Live Auction ___ Silent Auction
LOCATION CITY & STATE / DATE (a specific date must be provided. e.g. drawing date for raffle)
TITLE OF PRINT DONATION / Was it remarqued? ___ Yes ___ No / AMOUNT RAISED ON MOSS ART
$
NAME(S) OF WINNER(S) OF MOSS ART / AMOUNT RAISED IN TOTAL
$
DESCRIBE EVENT AND ANY SUPPORTING EVENTS (walks, dinner, etc.)
Additional Information
Are you working with a P. Buckley Moss Society Chapter? ___ Yes ___ No / Are you working with a Moss Dealer in your area? ___ Yes ___ No
CHAPTER NAME / DEALERSHIP NAME

CHAPTER CONTACT

/ DEALER ADDRESS CITY & STATE
COMMENTS & INFORMATION THAT MAY ASSIST OTHERS IN SIMILAR EVENTS

I pledged 10% of funds raised from this donation to the P. Buckley Moss Foundation for Children’s Education. A check made payable to the Moss Foundation is enclosed.