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pdf2013 Nomination Form—Page One
National Medal for Museum and Library Service
(To be filled out by the nominated institution.)
A. Cover Sheet
1. Legal Name of Your Institution:1
Organizational Unit (if different from Legal Name):
2. Institution Address
Street1: Street2:
City: County:
State:
Zip+4/Postal Code:
3. Telephone Number:
4. Fax Number:
5. Web Address: http://
6. Name of Institution’s Director/CEO:
Title:
E-mail:
Telephone Number:
7. Your Name (the person completing this form):
Title:
E-mail:
Telephone Number:
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 Museum3
Zoo
Other, please specify:
8. Type of Institution (check one):
Academic Library
Aquarium
Arboretum/Botanical garden
Art Museum
Children’s/Youth Museum
General Museum2
Historic House/Site
History Museum
Library Association
Library Consortium
Museum Library
Natural History /Anthropology Museum
If your institution is not an eligible entity on its own, then enter the name and address of the eligible entity under “Legal Name.”
For example, if a library that is part of a parent organization such as a university is applying, it would enter the university under
“Legal Name” and the library under “Organizational Unit.”
2
A museum with collections representing two or more disciplines (e.g., art and history)
3
A museum with collections limited to one narrowly defined discipline (e.g., textiles, stamps, maritime, ethnic group)
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2013 Nomination Form—Page Two
National Medal for Museum and Library Service
(To be filled out by the nominated institution.)
A. Cover Sheet (continued)
9. Governing Control (check one):
State Government
County Government
City or Township Government
Special District Government
Regional Organization
U.S. Territory or Possession
Independent School District
Public/State-Controlled Institution of Higher Education
Indian/Native American Tribal Government (Federally
Recognized)
Indian/Native American Tribal Government (Other
than Federally Recognized)
Indian/Native American Tribally Designated Organization
Public/Indian Housing Authority
Nonprofit with 501(c)3 IRS Status (Other than Institution
of Higher Education)
Nonprofit without 501(c)3 IRS Status (Other than
Institution of Higher Education)
Private Institution of Higher Education
Individual
For-Profit Organization (Other than Small Business)
Small Business
Hispanic-serving Institution
Historically Black Colleges and Universities (HBCUs)
Tribally Controlled Colleges and Universities (TCCUs)
Alaska Native and Native Hawaiian Serving Institutions
Nondomestic (non-U.S.) Entity
Other, please specify:
10. Nominated Institution’s D-U-N-S® Number:4
11. Nominated Institution’s Employer/Taxpayer Number (EIN/TIN):
12. Congressional District of Nominated Institution:
13. Institution’s Annual Operating Budget:
14.
Fiscal Year
List Total Revenue5/
Support Income
List Total Expenses6/
Outlays
List Any Budget
Deficit Amounts
Greater than 10% of
Total Revenue (if
applicable)7
List Any Budget
Surplus Amounts
Greater than 10% of
Total Revenue (if
applicable)7
Most recently completed
FY_____ (insert)
Second most recently
completed FY_____ (insert)
15. Complete a. and/or b.:
b. Attendance – onsite:
a. Population served: Attendance – offsite:
Verify that your institution has a D-U-N-S® Number or take steps to obtain one. Your institution can receive a D-U-N-S® Number
at no cost by calling the dedicated toll-free D-U-N-S® Number request line at 1-866-705-5711 or by visiting www.dnb.com/us.
5
For nonprofit tax filers Total Revenues can found on line 12 of the IRS Form 990.
6
For nonprofit tax filers Total Expenses can found on line 18 of the IRS Form 990.
7
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 as part of your response to Narrative Question 4 in this nomination form.
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2013 Nomination Form—Page Three
National Medal for Museum and Library Service
(To be filled out by the nominated institution.)
A. Cover Sheet (continued)
16. Number of full-time paid institution staff:
Number of full-time unpaid institution staff (including
volunteers):
Number of part-time paid institution staff:
Number of part-time unpaid institution staff (including
volunteers):
17. Total number of days the institution was open to the public for the 12-month period prior to application:
18. Name of Nominating Individual:
Title:
Relationship to Institution:
E-mail:
Telephone Number:
2013 Nomination Form—Page Four
National Medal for Museum and Library Service
(To be filled out by the nominated institution.)
In addition to the Cover Sheet (Section A), your submission must include the following parts (Sections B–E below). Do not include
additional cover letters, binders, folders, or attachments.
B. Statement of Purpose/Mission Statement & Brief Institutional History
Provide your institution’s mission statement or statement of purpose as well as a brief institutional history (not to exceed one
single-spaced page; no less than 12-point type).
C. Narrative
Address questions 1–4 thoroughly and succinctly, using no more than five single-spaced pages (no less than 12-point type) for
the four questions combined. The jurors considering the pool of potential medal recipients will focus carefully on your answers to
these questions.
1. Community: Quantify and describe the population groups/communities your institution is reaching through its community
services. What particular community needs do you address through your programs, services, and partnerships? How did you
identify these particular needs? Describe how your library or museum serves community members with special needs.
2. Programming: Provide examples of the programs and services you have developed for these population groups/communities. How does your institution involve your community in the development of your programs? How have these partnerships
increased your ability to reach out to the targeted population groups and communities you serve? How do your programs
reflect your institution’s mission and strategic plan?
3. Impact and Evaluation: Describe what impact your institution’s programs and services have had on the identified community
needs. Do you conduct a formal evaluation of your programs? If so, what you have learned about meeting the needs of your
audiences? How have you used this information to plan future programs and services?
4. Financial Sustainability: List the three primary sources of revenue that will sustain your institution in the future. Please describe any private or non-profit groups that support the mission and activities of your institution. If a budget surplus or deficit
for one or both of the two previous fiscal years is shown on the Cover Sheet, provide an explanation as part of this section of
the narrative.
D. Institutional Financial Statements
Include a copy of your institution’s financial statements for the past two complete fiscal years. If your fiscal year is complete but
not yet audited, please submit these unaudited figures and label them as such. If your institution is part of a larger organization
(municipal government, university, etc.) do not include financial statements for the parent organization, only for your institution.
E. Letters of Support (optional but strongly recommended)
Your institution may submit up to three letters of support with the Nomination Form. These letters should come from community
members who have direct knowledge of the institution’s community service. We recommend that the letters come from different
segments of the broader community served by the institution and from individuals who have either witnessed or experienced
first-hand a particular program or service. Nomination letters from members of Congress do not count against the three-letter
maximum. Address letters to the Director of the Institute of Museum and Library Services and include them with this Nomination
Form.
3137-0029; Expiration Date: 8/31/2013
| File Type | application/pdf |
| File Modified | 2012-07-03 |
| File Created | 2012-05-24 |