DCHS Temporary Custody Receipt

This is to acknowledge receipt of the items listed below by the The Dutchess County Historical Society. Printable form at right.

The online signature form is touch and trackpad sensitive.

For touchscreen devices such as smartphones and tablets, use your finger or special screen pen.
For desktops and laptops without touch feature use your mouse or trackpad.

Unfinished TC

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

The items listed below are left in the custody of the The Dutchess County Historical Society to be considered as (choose one):

An unconditional donation. The Museum reserves the right to keep, lend, or otherwise dispose of the donated material.
To be considered for acquisition.
To be considered for acquisition.
For identification. Does not constitute an authentication; will not include appraisals. Museum reserves the right to photograph.
For other please specify in space below:

Disposition if not accepted for accession (choose one):

Source will pick up
Please dispose of or destroy
May be sold to benefit DCHS

Item(s) description

Any images or documents you wish to add may be uploaded here:

Click or drag a file to this area to upload.

Signature of Donor/Lender

Signature: TOUCH & TRACKPAD SENSITIVE: Use your mouse or trackpad (laptop); For touchscreen devices such as smartphones and tablets, use your finger or special screen pen.

Signature on behalf of DCHS

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