Temporary Custody Receipt Form

Please complete this form to request temporary custody by OVHS for item evaluation and donation consideration.

Note: A Deed of Gift Agreement Form must be submitted first. The Collections Committee will advise if a Temporary Custody Receipt is required.

Temporary Custody Receipt Form

A Deed of Gift Agreement Form has already been submitted and you have been asked by the OVHS Colliections Committee to complete this Temporary Custody Receipt Form.

Yes

No

Please submit a Deed of Gift Agreement Form first.

Name(Required)

First Last

Address(Required)

Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Phone(Required)

Email(Required)

Items(Required)

List the specific item(s) named on the Deed of Gift Agreement Form for OVHS temporary custody:

Item Name

 

Add Remove

Attach any additional image(s) of item(s) that we not included in the Deed of Gift Agreement Submission:

Drop files here or Select files

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 32 MB.

Donor Agreement(Required)

The item(s) listed above are left in the custody of the Oro Valley Historical Society to be considered:

For Acquisition

As an Unconditional Donation - The Society reserves the right to keep, lend, or otherwise dispose of the donated item(s)

For Identification – It does not constitute an authentication and will not include an appraisal(s)

For Other Purposes – Please specify below

Please specify:(Required)

I agree that the Oro Valley Historical Society reserves the right to photograph the item(s.)(Required)

Yes

No

If the item is not accepted for acquisition by OVHS:(Required)

Applicant will pick up the item(s) within thirty (30) days – Note: if not picked up within 30 days, OVHS may dispose, destroy, sell, or keep the item(s).

OVHS is to dispose of or destroy the item(s)

OVHS may sell the item(s) to benefit the Society

Signature of Donor(Required)

By my signature below, I accept the foregoing conditions and acknowledge reading the Oro Valley Historical Society Collections Policy.

Date(Required)

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.