1.  Name:

2.  Organization:

3.  Address:

4.  City:   State/Province:    Zip/Postal Code:

5.  Business Phone:    Home Phone:

6.  E-Mail:

7.  Donor wishes bid proceeds from this donation to be applied to:
    
     (please indicate a specific program or fund, or leave blank if you wish the Foundation to apply proceeds where they are most needed.)

8.  Name of Item:

9.  Suggested Retail Value:

10. Minimum or starting bid should be set at:
    (leave blank if no minimum bid is required)

11. Photos/descriptions available at (web site URL):
   

12. Description:
   

13. Qualifying criteria, if any, for winning bidder: (please indicate any special restrictions, for example, clothing sizes, weight and/or height restrictions for rides, location where item must be delivered/collected, etc.)
   

14. Winning bidder collects product or service purchased by: (please provide all necessary contact information for arranging delivery after the auction, or indicate if item is to be picked up at the auction)
   

15. If the Foundation elects to hold an online auction NOT in conjunction with the ICAS convention, I acknowledge the possible inclusion of my donated product/service in that venue.  YES NO