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I would like to donate $__________ to have

______ pane(s) ($25 ea)    ______ window(s) ($300 ea)    ______ brick(s) ($5 ea)

registered under the name(s) of _____________________________________

Or in memory of _________________________________________________

(from the town of) ___________________________{State} ___________

Send the Certificate and Window Location Map to:

Name: ______________________________________

Address: ____________________________________

Town ___________________ State ____ Zip ______

Payment method:

(  )Check (Payable to Ashland Historical Society)

(  )VISA    (  )Mastercard    (  )Amex

(Credit Card charge will show as Tri-CountyCAP)

Card Account Number: _____  _____  _____  _____

Card Expiration Date  __  _____

Customer Signature:

Your Name _________________________________________________

(As it appears on your credit card)

Billing Address ______________________________________________

City _____________________________ State ________ Zip ______

Send the form to Ashland Historical Society PO Box 175, Ashland NH 03217

Note: If you would like to specify which window(s) you prefer to sponsor make a note of it here.   If it/they is/are still available when we receive this form it can be yours. The Windows Inventory shows which units are available. (Blue means taken, Green means available)