In-Kind Donation

Fields marked * require an entry.

If you would like to donate an Auction Item to be auctioned off at the "Party at the Palladium" on Saturday, September 18, 2010, please fill out the following form:

Item Information

Item Name:*

I would like to donate anonymously:

Yes

This is a joint gift from myself and:

Estimated Value $:*

Item Description:*

Notes:

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

No

Contact Information

Company:*

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Email:*