NLSI Moon Exhibit Request
Request for the Loan of a Specific Exhibit
I have read and agree to the
Loan Guidelines
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Contact Information
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First Name:
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Last Name:
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Organization:
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Address(1):
Address(2):
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City:
* State:
* Zip:
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Telephone:
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E-mail:
About the Exhibit
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Name of Requested Exhibit:
The Moon: Cosmic Decoder Ring
Treasure Hunt in Earth's Attic
Earth's Daughter
Impacts: Delivering Death and Fostering Life
Storm of Asteroids
Molten Moon
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Preferred Beginning Date for Exhibit Display:
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Preferred Ending Date for Exhibit Display:
Location Exhibit will be Displayed
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Name of Building:
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Street Address:
Room Name or Number, if any:
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City:
* State:
* Zip:
Other Information
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Type of Organization:
Library
Science Center
Planetarium
Museum
Other. Please describe:
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Please estimate your audience diversity:
% Hispanic
% African
American
% Caucasian
% American
Indian
% Asian
% Other
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How would you classify your community?
Rural
Urban
Suburban
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How would you classify the community income level?
upper
upper-middle
middle
lower-middle
lower
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Do you plan to have other activities related to the exhibit display? If so, what? (e.g. related resource display, family programs, childrens' programs, night viewing ...)
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If your organization is able to pay for shipping the exhibit to and from your site, it will allow support for shipping for other organizations that do not have funds; is your organization able to pay for some of the shipping costs for this exhibit?
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How did you learn about these traveling exhibits?
the Explore! library program
Museum Alliance
email from colleague
other (please describe)
Questions/Additional Information?
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If you see an error message, please correct and resubmit.