Form CAP Application 1 CAP Application 1 CAP Application

Application

1. General Information

Applicant institution: ___________________________________________________________

Applicant parent institution (if applicable): __________________________________________

Institutional mailing address: _____________________________________________________

City: _________________________ County: _________________________________

State: ____________ Zip: ___________ Closest metropolitan area: _______________________

Website: _____________________________________________________________________

EIN/TIN^ number: ________________________

Project Contact (Please note: The project contact should be the person who will administer the CAP Program for the institution. All CAP correspondence will be directed to this person. .)

 Dr.  Mr.  Ms.  Mrs.  Miss  Rev.  Prof.  Hon.

Name: _____________________________________________________________________

Title: ______________________________________________________________________

Phone: ________________________________

E-mail: ______________________________

If open seasonally, provide a phone number to reach staff in the off-season:

___________________________________________________________

Governing Control of Applicant (check one)

 state  county  municipal  private

 nonprofit  university  tribal government  other, specify: __________

Type of Organization (check one)

 Aquarium

 Arboretum/Botanical Garden

 Art Museum

 Children’s/Youth Museum

 General Museum (A museum with collections representing two or more disciplines equally, such as a museum of art and natural history.)

 Historic House/Site

 History Museum

 Natural History Museum/ Anthropology Museum

 Nature Center

 Planetarium

 Science/ Technology Museum

 Specialized Museum (A museum with collections limited to one narrowly defined discipline, such as a maritime museum.)

 Zoological park

 Other (please specify: _______________________________________)

Does your institution have a parent organization?

If yes, what is the name of the parent organization? ______________________________

In what year was the institution first open to the public? ____________________________

What is your institution’s mission statement?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3 . Eligibility

 Yes  No Does the institution exist on a permanent basis for essentially educational or aesthetic purposes?

 Yes  No Does the institution own tangible objects, whether animate or inanimate?

 Yes  No Are these objects available to the public through exhibition and/or research on a regular basis?

 Yes  No

 Yes  No Does the institution have at least one full-time paid or unpaid staff member or the equivalent combination of part-time staff, whose responsibilities relate solely to the institution’s professional activities?

 Yes  No Can assessors review the entire collection and buildings within a two-day site visit?

2. General Operating Budget

What was your institution’s approximate operating budget for the most recently completed operating year: $___________________

3. Staff

Number of paid staff:

Full-time __________

Part-time _________

Number of non-paid staff:

Full-time __________

Part-time __________

List the key staff (paid and volunteer) who will work on this CAP assessment, along with their average hours per week. Since job titles vary among institutions, please explain each staff member’s responsibilities.

Name: Title:

 Volunteer or  Paid

Hours per week: ____________

Responsibilities: ____________________________________________________________

Name: Title:

 Volunteer or  Paid

Hours per week: ____________

Responsibilities: ____________________________________________________________

Name: Title:

 Volunteer or  Paid

Hours per week: ____________

Responsibilities: ____________________________________________________________

Name: Title:

 Volunteer or  Paid

Hours per week: ____________

Responsibilities: ______________________________________________________________

Name: Title:

 Volunteer or  Paid

Hours per week: ____

Responsibilities: ______________________________________________________________

Name: Title:

 Volunteer or  Paid

Hours per week: ____________

Responsibilities: ________________________________________________________________

(Attach a list of additional relevant staff if necessary.)

4. Goals

What goals does the organization have for this assessment? (Check all that apply.)

 Develop a long-range preservation/conservation plan^ for collections

 Improve collections care^

 Increase staff and board awareness of collections conservation^ concerns

 Improve the preservation^ of the building

 Improve environmental conditions

 Improve storage conditions

 Use as a tool to obtain funding for collections care

 Prepare for accreditation

 Other: ______________________________________________________________

Comments/special concerns: ________________________________________________

________________________________________________________________________

5. Site Information

Site area:

 less than 1 acre

 1-5 acres

 6-10 acres

 more than 10 acres

How many buildings hold collections storage or exhibitions? _____________________________

Are they all on the same site?  Yes  No

If no, where are the buildings located? ____________________________________________________________________________________________________________________________________________________________

Does your organization own all of the land and buildings it occupies?  Yes  No

If not, please explain.

___________________________________________________________________________________________________________________________________________________________

6. Building Information

Complete the following section for each structure that houses collections storage or exhibition space. Attach additional pages if necessary.

Building #1

Building name: ________________________________________________________________

Number of stories: __________

Approximate square footage or dimensions: _____________

Type of structure:

 modern building built as a museum or collections space

 older building (50 years or older) built as a museum or collections space

 older or historic structure not originally designed as a museum or collections space

 building shared with other non-museum activities (approximate square

footage of museum exhibition and storage spaces: ______________)

 other: ______________________________________________________

Approximate construction date: __________________

Does the building have additions?  Yes  No

If yes, please list approximate construction date(s) of the additions: ___________________

This structure is used for (check all that apply):

 collections storage

 exhibits (with artifacts)

 office space

 other: ______________________________________________________

Building #2 (if applicable)

Building name: ________________________________________________________________

Number of stories: __________

Approximate square footage or dimensions: _____________

Type of structure:

 modern building built as a museum or collections space

 older building (50 years or older) built as a museum or collections space

 older or historic structure not originally designed as a museum or collections space

 building shared with other non-museum activities (approximate square

footage of museum exhibition and storage spaces: ______________)

 other: ______________________________________________________

Approximate construction date: __________________

Does the building have additions?  Yes  No

If yes, please list approximate construction date(s) of the additions: ___________________

This structure is used for (check all that apply):

 collections

 storage

 exhibits (with artifacts)

 office space

 other: ______________________________________________________

Building #3 (if applicable)

Building name: ________________________________________________________________

Number of stories: __________

Approximate square footage or dimensions: _____________

Type of structure:

 modern building built as a museum or collections space

 older building (50 years or older) built as a museum or collections space

 older or historic structure not originally designed as a museum or collections space

 building shared with other non-museum activities (approximate square

footage of museum exhibition and storage spaces: ______________)

 other: ______________________________________________________

Approximate construction date: __________________

Does the building have additions?  Yes  No

If yes, please list approximate construction date(s) of the additions: ___________________

This structure is used for (check all that apply):

 collections

 storage

 exhibits (with artifacts)

 office space

 other: ______________________________________________________

If your site contains more than three structures that house collections, please upload a document that lists all additional structures. Please include all information requested above for each structure.

7. Additional Information

Does your institution have a written Collections Management Policy?  Yes  No

Does your institution have a written Emergency Preparedness Plan that includes directives on the

collections?  Yes  No

Are funds regularly expended on the collections conservation?  Yes  No

If yes, how does your institution allocate funds for conservation (check all that apply):

 Collections conservation is an item in our annual budget

 Funds are allocated in response to a need

 Funds are sought through grants or donations in response to a need

 Other: ______________________________

8. Proof of nonprofit status

You must attach proof of the institution’s nonprofit status with either:

• a copy of the federal IRS letter indicating the institution’s eligibility for nonprofit status under the application provisions of the Internal Revenue Code of 1954, as amended.

1. If the name on the IRS letter differs from the applicant institution because of a name change, submit a letter of explanation on the institution’s letterhead and signed by a director or board official.

2. If the name or TIN on the IRS letter differs from the applicant institution because the IRS letter of a parent organization is being used, submit a letter explaining the relationship between the two organizations on the parent organization’s letterhead and signed by an official at the parent organization.

• (For institutions that are a unit of local, state, or tribal government only) A letter identifying the institution as a unit of government on that entity’s letterhead and signed by an official at that entity.

FAIC will not accept a letter of sales tax exemption or a copy of the institution’s tax returns as proof of nonprofit status.

9. Certification

Participants in the Collections Assessment for Preservation program must obtain the approval of their board or governing body before applying to the program. To demonstrate this approval, please designate a board or governing body official who will serve as the Authorizing Official. The Authorizing Official should be an executive member of the organization’s governing body, the head of the sponsoring organization, or the government official responsible for oversight of the institution. The Authorizing Official should be different from the project contact.

When the application is complete, the Authorizing Official must complete the information below. In the event that FAIC staff is unable to reach the institution’s staff for questions about the CAP application or the organization’s participation in the program, the Authorizing Official listed below will be contacted.

Statement of Authorizing Official:

I am a member of the Board of Directors or Governing Body, or the Government Official responsible for oversight of the organization, and am authorized to submit this application to the 2017 Collections Assessment for Preservation program. I certify that all of the information contained in this application is true and accurate to the best of my knowledge. Should our institution be chosen to participate in the program, our staff will be responsible for complying with all requirements and guidelines of the Collections Assessment for Preservation program.

Signature of Authorizing Official: ______________________________ Date: _____________

Please fill in the information below.

 Mr.  Ms.  Dr.

Name: ____________________________________ Title: _______________________________

Phone: ____________________________________

E-mail: ______________________________________

Supplement A: For Museums and Historic Sites

Is a significant portion of the collection held on loan, or owned by another institution?

 Yes  No

Has the institution ever engaged a consultant to survey all or part of the collections?

 Yes  No

Please share the approximate size and composition of your collection by placing an “x” in the appropriate column for each collection type in the chart below. Exact numbers are not expected. Please estimate to the best of your ability.

Collection type Number of Objects

	0	1 - 100	101 - 1,000	1,001 -10,000	10,001+
Archaeological/paleontological artifacts
Arms and armor/weapons
Botany (live)
Botany (herbaria)
Ceramics and glass
Digital (born-digital)
Ethnographic artifacts
Furniture
Geology/mineralogy
Historic objects
Industrial/agricultural tools and equipment
Leather/animal hides
Library/books/archival materials
Metal objects
Musical instruments
Paintings
Photographic materials
Science/technology/medicinal artifacts
Sculpture
Stone objects
Taxidermy
Textiles and costume
Time based media (film, audio recordings, etc.)
Transportation vehicles
Works on paper
Wet collections/fluid preserved collections
Wood objects
Zoology (live)
Zoology (preserved)
Other (specify:)

Total number of objects in the collection (please estimate if exact numbers are unavailable): ____________

How many staff members participated in gather information for this application? ____________

How many hours did it take for your institution to complete this application? (Consider total hours contributed by all staff members.) ______________ hours

Supplement B: For Arboreta and Botanical Gardens

1. Collections and Collection Records

In order to best match an institution with conservators, we ask that you share the approximate size and composition of your collection by answering the questions below. Exact numbers are not expected. Please estimate to the best of your ability.

Approximately how many different living plant species does the institution maintain? ___________

Approximately how many herbarium^ specimens does the institution maintain? ___________

What is the size and composition of the institution’s collections? (check one box for each row)

	0	1 - 100	101 - 1,000	1,001 +
Woody
Non-woody
Hardy at site
Not hardy
Annual/Seasonal

2. Facilities Information

Approximately what percentage of the land is used for:

Cultivated collections? ____ %

Natural areas? ____ %

Visitor services (restrooms, picnic areas, parking lots, etc.)? ____%

Administration and maintenance? ____%

other: ____ %

3. Non-Living Collections

Are there non-living collections that the institution wishes to have assessed?

 Yes  No

If yes, please complete Supplement A: For Museums and Historic Sites in addition to this Supplement.

How many staff members participated in gather information for this application? ____________

How many hours did it take for your institution to complete this application? (Consider total hours contributed by all staff members.) ______________ hours

Supplement C: For Zoos and Aquariums

1. General Information

Is the institution accredited by the Association of Zoos and Aquariums?  Yes  No

If yes, date: ____________________

. If you are AZA-accredited, the CAP Program will only cover your facilities and non-living collection.

2. Collections and Collection Records

Select the number range that best describes the approximate number of species and specimen in your collection for each group. Please estimate to the best of your ability.

	Number of Species	Number of Specimen
Birds
Fish
Invertebrates
Mammals
Reptiles and Amphibians
Other (specify):

3. Facilities Information

Approximately what percentage of the land is used for:

Animal habitats? ____ %

Natural areas? ____ %

Picnic and recreation areas? ____%

Administration and maintenance? _____%

Other? ____ %

4. Non-Living Collections

Are there non-living collections that the institution wishes to have assessed?

 Yes  No

If yes, please complete Supplement A: For Museums and Historic Sites in addition to this Supplement.

How many staff members participated in gather information for this application? ____________

How many hours did it take for your institution to complete this application? (Consider total hours contributed by all staff members.) ______________ hours

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