Senior Design Project – Gift in Kind Information Form

Date: ___________________________________________________________

Company Name: ___________________________________________________________

Mailing Address: ___________________________________________________________

City: ______________________ State & Zip: ____________________

Phone Number: ___________________________________________________________

Contact Name: ______________________ Contact Title: ____________________

Senior Design Team: _________________________________________________________

Description of Property, Goods, Services, or other Gift:

Value: ____________________________________________________________________

Acknowledgment: I acknowledge this gift was made to the above-specified Senior Design Team and that no

goods or services were provided in exchange for this gift.

_______________________________________ __________________________________

Name Signature