Amount $_________________ Date________________

In Memory of __________________________________________________________

How would you like the bookplate to read? _________________________________

_____________________________________________________________________

Given by _____________________________________________________________

_____________________________________________________________________

Address ______________________________________________________________

_____________________________________________________________________

Card set to ____________________________________________________________

______________________________________________________________________

__ No thanks. A card has already been sent.

Special notes: (I.e. “Please buy a book” or “Use for building fund”)

___________________________________________________________

___________________________________________________________

___________________________________________________________

__ Please check here if you do not need an acknowledgment.

Mail form: Allegany Public Library
90 W. Main St.
Allegany, NY 14706

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