ALTA Spectrometer Classroom Set Request

Request for the Loan of a Specific Exhibit

I have read and agree to the Loan Guidelines

After we receive your request, we will respond within 10 business days. We will later send you the link to the online loan agreement within 1-2 months before the period of the loan. Please fill it out within 10 business days of receiving the email request from us.

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Contact Information

First Name:

Last Name:

Organization:

Address(1):

Address(2):

City:

* State: * Zip:

Telephone:

E-mail:

Preferred Arrival Date for Classroom Set:

Preferred Return Date for Classroom Set
(maximum of 30 days):

Alternate Contact
Please provide an alternate contact, in the event that you are away when we ask you to fill out the online loan agreement.

Name:

Email:

Other Information

Type of Organization:

School
Science Center
University
Other. Please describe:

Please estimate your audience diversity:

% Hispanic	% African American	% Caucasian	% American Indian	% Asian	% Other

How would you classify your community?

Rural Urban Suburban

How would you classify the community income level?

upper upper-middle middle lower-middle lower

Which activities or lessons will you use with the ALTA spectrometers?

Which class(es) will use the ALTAs? (Subject and grade level)

Please select which way you would like to cover shipping the ALTA classroom kits:

I will provide credit card information in the online loan agreement that will be charged $100 to help cover shipping costs.
I will provide my organization's FedEx account information for LPI to use to ship the ALTAs to me. I understand that LPI cannot estimate what my shipping charges will be.
I will pick up and return the ALTAs in person.

How did you learn about the ALTA classroom kits?

workshop
website
email from colleague
other (please describe)

Questions/Additional Information?

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If you see an error message, please correct and resubmit.