Sheet1OPEN HOUSE SA LIGHTHOUSE DONATION FORM

Name:Date

Lighthouse DistictContact Number:

Pick UpHand Carry Received By:

QuantityItem Name and DescriptionDeclared Value

I hereby certify that all the items above are in good and working condition. I understand that t is my responsibility to declare whatever defects the above items may have. Furthermore, I take responsibility for any damage or injury that these items may cause and shall hold free from liability the organizers and officers of this event.

Name and SignatureDate:

OPEN HOUSE SA LIGHTHOUSE DONATION FORM

Name:Date

Lighthouse DistictContact Number:

Pick UpHand Carry Received By:s

QuantityItem Name and DescriptionDeclared Value

I hereby certify that all the items above are in good and working condition. I understand that t is my responsibility to declare whatever defects the above items may have. Furthermore, I take responsibility for any damage or injury that these items may cause and shall hold free from liability the organizers and officers of this event.

Name and SignatureDate:

Sheet2

Sheet3