INCOMING RELIC LOAN REGISTRATION FORM Form Code: HSW-F12

 HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM

INCOMING RELIC LOAN REGISTRATION FORM

Form Code: HSW-F12

Loan Reference Number: _______________________

Date Received: ____ / ____ / ______

1. RELIC DETAILS

   1.1 Temporary Relic ID Code: __________________

   1.2 Relic Name / Title: ______________________

   1.3 Description:

       _________________________________________

       _________________________________________

2. LENDING INSTITUTION / PERSON

   2.1 Name of Institution / Person:

       _________________________________________

   2.2 Address:

       _________________________________________

       _________________________________________

   2.3 Contact Person:

       Name: _________________________________

       Phone / Email: ________________________

3. LOAN AGREEMENT

   3.1 Loan Agreement Number / Title:

       _________________________________________

   3.2 Main Loan Conditions (summary):

       _________________________________________

       _________________________________________

4. CONDITION ON ARRIVAL

   4.1 Condition:

       [ ] Excellent  [ ] Good  [ ] Fair  [ ] Poor

   4.2 Notes on Damage / Risk:

       _________________________________________

       _________________________________________

5. STORAGE / DISPLAY PLAN

   5.1 Intended Location(s):

       Storage: ________________________________

       Display: ________________________________

   5.2 Planned Display Dates (if any):

       From: ____/____/____  To: ____/____/____

6. RETURN DETAILS (to be completed later)

   6.1 Planned Return Date: ____/____/____

   6.2 Actual Return Date: ____/____/____

   6.3 Condition on Return:

       _________________________________________

Received By (HSWAGATA):

Name: _________________________  Signature: __________

Date: ____/____/____