HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM
RELIC PROVENANCE & HISTORY DECLARATION
Form Code: HSW-F04
Relic ID Code: ____________________________
Date: ____ / ____ / ______
1. DECLARANT (OWNER / DONOR) DETAILS
1.1 Full Name: ________________________________
1.2 Role (owner / donor / representative):
__________________________________________
1.3 Address:
__________________________________________
__________________________________________
1.4 Phone / Email:
__________________________________________
2. PROVENANCE STATEMENT
Please explain how the relic was obtained and its journey
before coming to HSWAGATA.
2.1 How did you first receive or know this relic?
__________________________________________
__________________________________________
2.2 Known previous locations (temples, homes, countries):
__________________________________________
__________________________________________
2.3 Known previous custodians (names, roles):
__________________________________________
__________________________________________
3. EVIDENCE / SUPPORTING MATERIAL
3.1 Documents provided:
[ ] Donation letter
[ ] Old photographs
[ ] Legal / temple letters
[ ] Scientific reports
[ ] Other: ____________________________
3.2 Short description of key evidence:
__________________________________________
__________________________________________
4. DECLARATION BY DONOR / OWNER
I declare that the information I have given is true to
the best of my knowledge.
Name: ________________________________________
Signature: ___________________ Date: ____/____/____
5. MUSEUM RECEIVING SECTION
5.1 Receiving Officer (name): _________________________
5.2 Signature: __________________ Date: ____/____/____
5.3 Notes / Comments:
__________________________________________
__________________________________________
