Donor Questionnaire Fields marked with an asterisk (*) are required. "*" indicates required fields Step 1 of 7 – Donor Information 14% Donor InformationName* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Enter Email Confirm Email Mobile*Phone About the ObjectDescription* Upload Image(s) of the Object Drop files here or Select files Max. file size: 60 MB. Acquisition HistoryDate Acquired MM slash DD slash YYYY How did you acquire the object?* Purchase Inheritance Other Gift Found If “other”, please explain.* If the object was purchased, do you have a bill of sale, certificate or any items relating to the transaction or the object's authenticity?* Yes No If yes, please attach a copy (or copies) to this questionnaire. Drop files here or Select files Max. file size: 256 MB. Were there any known previous owners?* Yes No If yes, please list all known previous owners and their relationship to the donor*Previous Owner's NameRelationship to Donor Add Remove(Click on the “+” sign to add rows.) Exhibition & PressDo you know the exhibition history of the object?* Yes No If yes, please list.Exhibition NameLocationDate Add Remove(Click on the “+” sign to add rows.) Do you have any published information or press clippings about the object?* Yes No If yes, please attach a copy (or copies) to this questionnaire. Drop files here or Select files Max. file size: 256 MB. Treatment HistoryHave you performed any cleaning, repairs, made changes to the object or contracted a conservator to do so while this object was in your care?* Yes No If yes, please list names, dates, cleanings, repairs, changes, etc., and attach copies of any relevant paperwork and/or photographs.Change/RepairDateConservator/Technician Add Remove(Click on the “+” sign to add rows.)Attach copies of any relevant paperwork and/or photographs. Drop files here or Select files Max. file size: 256 MB. Do you know if this object was conserved/restored prior to your ownership?* Yes No Don’t Know If yes, please list all known treatments, dates and conservators used.TreatmentDateConservator Add Remove(Click on the “+” sign to add rows.)Attach copies of any relevant paperwork and/or photographs. Drop files here or Select files Max. file size: 256 MB. Credit LineDesired Credit Line*e.g. “Gift of [your name]”; or “Gift of [your name] in memory of [name individual being remembered]” LegalDo you intend to take a tax deduction of greater than $5000 for this object?* Yes No Terms & Conditions* I have read and agree to the Terms & ConditionsTerms & Conditions • All donations require the approval of the Tracing Patterns Foundation (TPF). TPF reserves the right to decline any donation for any reason. • It is the responsibility of the Donor to advise TPF if they intend to take a tax deduction of greater than $5,000. • All donations are recorded in the year that they are received. * I HEREBY CERTIFY that the information provided in this form is complete, true and correct to the best of my knowledge. CommentsThis field is for validation purposes and should be left unchanged.
