Date: ______________

Donor of Book:        Name _________________________________________

                                Address _______________________________________

                                Phone # _____________________________

Label on book to read as:
                                In Memory of _________________________________________________  (OR)

                                In Honor of ___________________________________________________

                                Donated by ___________________________________________________

Name of teacher or student to notify about book dedication:

                                Name ___________________________________________   Room _________ (OR)

Name and address of family member to be notified of gift:

                                Name _________________________________________________________________

                                Address ________________________________________________________________

Suggested subject area(s) for book selection ____________________________________________________

Number of books for librarian to purchase __________       Approximate cost of each book _____________

ATTACH CHECK PAYABLE TO: Broad Street Elementary Library

ANY QUESTIONS, CALL (724) 214-3560, EXT. 5571

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(to be completed by school librarian)

Books ordered and received: _____________________________________________________________________________

Author of book: _________________________________________________________________

Publisher/copyright: __________________________________________________________________________________

Cost of book: ___________________________________________________________________
(any unused funds will be used for future library book purchases)