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i Institute of Museum Services <br />General Operating Support Form No. 102 <br />jImportant: Refer to instructions on facing page Department Health, <br />an <br />I Education, and Welfare <br />Washington, D.C. 20201 <br />I Form Approved: OMB No. 51 -R1260 <br />CFDA No.: 13.923 f Application No. <br />A. APPLICANT (Use blocks provided. Abbreviate if necessary.) <br />1. <br />i Is Ic lo I v le I r <br />I y I <br />I Hal <br />I 1ETmFul <br />se u <br />Name of Museum <br />2a <br />o 1 <br />os I el <br />DI h <br />Museum's Street Address <br />2b <br />City <br />State Zip Code <br />3. <br />M 6 Ir 13 1h a I 1A <br />nn <br />I <br />M u 1 <br />1 i n <br />Museum Contact Person <br />Telephone No. <br />4. <br />Name of Sponsoring Institution <br />5. <br />F073 6. FoF5-1 7. <br />13 15 <br />16 <br />10 10111210111 <br />8. <br />Cong. Dist. HEW Region <br />Fed. Employer <br />I.D. Number <br />Federal Tax Exempt Number <br />3. CONTROL OF MUSEUM T C. TYPE OF MUSEUM ❑ <br />D. FINANCIAL INFORMATION <br />1. 1979............ <br />2.1980............ <br />3.1981 ............ <br />4. Amount Requested <br />G. PREVIOUS IMS AWARDS <br />■NN oil <br />■■RM13=111 1 11 <br />©©MME 11 <br />1978 Amount <br />GOS ❑ $ [:=.00 <br />SP ❑ $ I I.00 <br />H. INSTITUTIONAL INFORMATION <br />1. Enter the museum's estimated annual attendance. <br />E. GRANT AWARD PERIOD <br />October 1, 1980 through September 30, 1981 <br />F. OTHER IMS SUBMISSIONS FOR CURRENT GRANT CYCLE <br />Special Project ❑ <br />1979 Amount <br />GOS ❑ $ 1 1 1 1 1 1.00 <br />SP ❑ $ .00 <br />2. Enter the year in which the museum was first opened to the public . . . . . . . . . . . . . . . . . . . . .. . . ... .. . . .. <br />3. Enter the number of full -time paid staff . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .... . ... . .. <br />4. Enter the number of part-time paid staff . . . . . . . . . . . . . . .. . . . . . .. . ... . . . . . . . . ... .... .. ....-- 1- 1-J�lJ <br />5. Enter the number of full -time unpaid staff . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. ... . . . . ... . . . . .. I --;- -1 1 0 <br />6. Enter the number of part-time unpaid staff . . . . . . . .. . . . . . . . . . . . . . . . .. . . .. . . ... ..... .. . . . . L-1 2 <br />7. Enter the size of the museum facility's exhibition space (in square feet or acres). 12 +000 sq. ft. acres <br />8. Enter the size of the museum facility's total space (in square feet or acres). 22'000 sq. ft acres <br />CERTIFICATION BY AUTHORIZING OFFICIAL <br />(Name and title of museum's authorized representative - please type) <br />(Signature) I do hereby agree to comply with all requirements pursuant to the regulations of the Museum Services Program. (Date signed) <br />(continued on other side) <br />