Form Application Form 1 Application Form 1 Program Information Sheet

Program information sheet - page one

1. Applicant Information
a. Legal Name (5a from Face Sheet):
b. Organizational Unit (if different from Legal Name):
c. Organizational Unit Address
Street1:

Street2:

City:

County:

State:

Zip+4/Postal Code:

d. Web Address: http://
e. Type of Institution (check one):
Academic Library
Aquarium
Arboretum/Botanical garden
Art Museum
Children’s/Youth Museum
Community College
Four-year College
General Museum*
Graduate School of Library and
Information Science
 Historic House/Site
 Historically Black College or
University
 History Museum
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Library Association
Library Consortium
Museum Library
Museum Services Organization/
Association
Native American Tribe/Native
Hawaiian Organization
Natural History /Anthropology
Museum
Nature Center
Planetarium
Public Library
Research Library/Archives

 School Library, or School District
applying on behalf of a School
Library or Libraries
 Science/Technology Museum
 Special Library
 Specialized Museum**
 State Library
 State Museum Agency
 State Museum Library
 Zoo
 Institution of higher education other
than listed above
 Other, please specify:

*A museum with collections representing two or more disciplines equally (e.g., art and history)
**A museum with collections limited to one narrowly defined discipline (e.g., textiles, stamps, maritime, ethnic group)

2. Grant Program or Grant Program Category
 a. 21st Century Museum
Professionals
 b. American Heritage
Preservation Grants
c. Connecting to Collections:
Statewide Grants
 Planning
 Implementation
 d. Congressionally Directed
Grants
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e. Conservation Project Support
General Conservation Survey
Detailed Conservation Survey
Environmental Survey
Environmental Improvements
Treatment
Training

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f. Laura Bush 21st Century
Librarian Program
Master’s-level Programs
Doctoral-level Programs
Pre-professional Programs
Research (early career
development)
Research (other than early career
development)
Continuing Education
Programs to Build Institutional
Capacity

 g. Museum Grants for African
American History and Culture
h. Museums for America
 Engaging Communities
 Building Institutional Capacity
 Collections Stewardship

i. National Leadership Grants
Select Museum or Library:
 Museum
 Library
Select Funding Category:
 Project Grant
 Collaborative Planning Grant
Select Project Category:
 Advancing Digital Resources
 Demonstration
 Library Museum Collaboration
 Research

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j. Native American/Native
Hawaiian Library Services
Basic Grant only
Basic Grant with Education/
Assessment Option
Enhancement Grant
Native Hawaiian Library Services

k. Native American/Native
Hawaiian Museum Services
 Programming
 Professional Development
 Enhancement of Museum Services

Program information sheet - page two

3. Request Information
a. IMLS funds requested:

b. Cost share amount:

4. Museum Profile (Museum Applicants only)
a. Is the institution either a unit of state or local government or a private not-for-profit organization that has taxexempt status under the Internal Revenue Code and that is organized on a permanent basis for essentially
educational or aesthetic purposes?
 Yes
 
No
b. Does the institution own or use tangible objects, whether animate or inanimate?
c. Does the institution care for tangible objects, whether animate or inanimate?

 Yes
 Yes

 No
 No

d. Are these objects exhibited by the institution to the general public on a regular basis through facilities the
institution owns or operates?
 Yes
 
No
e. Is the institution open and exhibiting tangible objects to the general public at least 120 days a year through
facilities the institution owns or operates?
 Yes
 No
   Institution’s attendance for the 12-month period prior to the application: Onsite:
Offsite:
   Year the institution was first open and exhibiting to the public:
   Total number of days the institution was open to the public for the 12-month period prior to application:
f. Does the institution employ at least one professional staff member, or the full-time equivalent, whether paid or
unpaid, who is primarily engaged in the acquisition, care, or exhibition to the public of tangible objects owned or
used by the institution?  Yes
 No
    Number of full-time paid institution staff:
   Number of part-time paid institution staff:
g.

Fiscal year

Revenue/
Support income

Expenses/
Outlays

Number of full-time unpaid institution staff:
Number of part-time unpaid institution staff:
Budget deficit
(if applicable)*

Budget surplus
(if applicable)*

Most recently
completed FY
Second most recently
completed FY
*If Institution has a budget deficit or surplus for either of the two most recently completed fiscal years, please
explain the circumstances of this deficit or surplus in the Text Responses section of the application.

5. Project Partners
In the space below, please list the names of any organizations that are official partners in the project. All official
partners must include a completed Partnership Statement Form in this application package.

6. Native Hawaiian Organization Eligibility (Native American/Native Hawaiian Programs only)
Is the institution an eligible not-for-profit organization that primarily serves and represents Native Hawaiians (as defined
in Title 20 U.S.C. Section 7517; if yes, see Proof of Eligibility requirements)?
 Yes
 No

Program information sheet - page three

7. Institutional Profile (Native American Library Services Grants only)
a. Number of hours per week the library collection is accessible to patrons:
b. Number of staff dedicated full-time to library operations:
c. Number of staff with part-time library duties:
d. Number of items in the collection (books, journals, media):
e. Number of items checked out per year:
 No
f. Does library staff have access to the Internet?  Yes
 No
g. Does the library provide public access to the Internet?
 Yes
h. Amount of operating budget for library services in most recently completed fiscal year: $
i. Identify which of the following activities will be supported by grant funds (check all that apply):

Expand services for learning and access to information and educational resources.
Develop library services that provide all users with access to information.
Provide electronic and other linkages between and among all types of libraries.
Develop public and private partnerships with other agencies and community-based organizations.
Target library services to help increase the access and the ability to use information resources for individuals of diverse
backgrounds, with disabilities, or with limited functional literacy or information skills.
 Target library and information services to help increase the access and the ability to use information resources for persons
having difficulty using a library, and for underserved urban and rural communities.
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j. Maintenance of Effort (check the appropriate response):

 FY 2010 expenditures will equal or exceed previous 12 month grant period. Maintenance of effort is assured.
 FY 2010 expenditures will not equal or exceed previous 12 month expenditure. Maintenance of effort is not assured.
 Maintenance of effort does not apply.

8. Collection and Material Information (Conservation Project Support Grants only)
a. Type of Collection
 Nonliving
 Animals, living

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Natural History/Anthropology
Plants, living

b. Types of Materials. Use a scale from 1 (primarily affected) to 4 (minimally affected) to show which collection types
are primarily affected by the project:
aeronautics, space/airplanes
animals, live
animals, preserved
anthropologic, ethnographic
archaeological
books
ceramics, glass, metals, plastics
documents, manuscripts
furniture/wooden objects
geological, mineral,
paleontological
historic buildings
historic sites

horological (clocks)
landscape features, constructed
machinery
maritime, historic ships
medals
medical, dental, health,
pharmacological
military, including weapons
motion picture, audiovisual
musical instruments
numismatics (money)
paintings
philatelic (stamps)

photography, negatives
photography, prints
physical science projects
plants, live
plants, preserved
sculpture, indoor
sculpture, outdoor
textiles and costumes
tools
toys and dolls
transportation, excluding
airplanes
works of art on paper

OMB Number: 3137; expires 07/31/2010. Est. completion time for this form: 20 min. Full burden statement in Guidelines.