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		Library Association		School Library or School District applying on behalf of a School Library or Libraries
Aquarium		Library Consortium
Arboretum/Botanical Garden		Museum Library
Art Museum		Museum Services Organization/ Association		Science/Technology Museum
Children’s/Youth Museum				Special Library
Community College		Native American Tribe/Native Hawaiian Organization		Specialized Museum **
Four-year College				State Library
General Museum*		Natural History/Anthropology Museum		State Museum Agency
Graduate School of Library and Information Science				State Museum Library
		Nature Center		Zoo
Historic House/Site		Planetarium		Institution of higher education other than listed above
Historically Black College or University		Public Library
		Research Library/Archives		Other, please specify:      
History Museum
*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, maritime, ethnic group)

2. Grant Program or Grant Category
a. 21st Century Museum Professionals b. Congressionally Directed Grants c. Connecting to Collections: Statewide Grants d. Conservation Project Support General Conservation Survey Detailed Conservation Survey Environmental Survey Environmental Improvements Treatment Training e. Grants for Learning Labs in Libraries and Museums  Select Museum or Library: Museum Library	f. Laura Bush 21st Century Librarian Program Select Funding Category: Project Grant Collaborative Planning Grant National Forum Planning Grant Select Project Category: Master’s-level Programs Doctoral-level Programs Research: Early Career Development Continuing Education Programs to Build Institutional Capacity Scholarship Continuation 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 Level 1 Collaborative Planning Grant Level 2 Select Project Category: Advancing Digital Resources Demonstration Library Museum Collaboration Research j. Native American/Native Hawaiian Library Services Basic Grant only Basic Grant with Education/ Assessment Option Enhancement Grant Native Hawaiian Library Services continued on next page...

PROGRAM INFORMATION SHEET – PAGE TWO

2. Grant Program or Grant Category (cont’d)
k. Native American/Native Hawaiian Museum Services Programming Professional Development Enhancement of Museum Services	l. Sparks! Ignition Grants Select Museum or Library: Museum Library

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 tax-exempt 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? Yes No

c. Does the institution care for tangible objects whether animate or inanimate? Yes 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 fulltime 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 full-time unpaid institution staff:      
Number of part-time paid institution staff:      	Number of part-time unpaid institution staff:      

g.

Fiscal year	Revenue/ Support Income	Expenses/ Outlays	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 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:      

f. Does library staff have access to the Internet? Yes No

g. Does the library provide public access to the Internet? Yes No

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.

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

Art History

Natural History Anthropology

Living Plants Living Animals

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	  horological (clocks)	  photography, negatives
  animals, live	  landscape features, constructed	  photography, prints
  animals, preserved	  machinery	  physical science projects
  anthropologic, ethnographic	  maritime, historic ships	  plants, live
  archaeological	  medals	  plants, preserved
  books	  medical, dental, health, pharmacological	  sculpture, indoor
  Ceramics, glass, metals, plastics		  sculpture, outdoor
  documents, manuscripts	 military, including weapons	  textiles and costumes
  furniture/wooden objects	  motion picture, audiovisual	  tools
  geological, mineral, paleontological	  musical instruments	  toys and dolls
	  numismatics (money)	  transportation, excluding airplanes
  historic building	  paintings
  historic sites	  philatelic (stamps)	  works of art on paper

5 | OMB Number 3137-0071, Expiration date: 08/31/2013.