Fillable New Renewal Arizona Historical Society Certified Museum Program

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New Renewal Arizona Historical Society Certified Museum Program

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Grant Program.Grant Final Report Form.1.5.2.3
Page 1
Arizona Historical Society
Certified Museum Program
2018 APPLICATION
□New □Renewal
Date: _____________________
Name of Organization ____________________________________________________________
Mailing Address _____________________________________________________________
City ____________________________________ Zip ____________________________________
Physical Address _________________________________________________________________
City ___________________________________ Zip ____________________________________
Phone _________________________________ Email __________________________________
Contact Person __________________________________________________________________
Phone if different than above ______________________________________________________
Email if different than above ______________________________________________________
Date of Incorporation ___________________________ 501(c)(3) □ Yes □ No
Mission Statement: Date Adopted ________________ Date Revised ______________________
Attach a copy of current mission statement.
Not-for-Profit Status Current □ Yes □ No
By-laws Current □ Yes □ No
Governing Body □ Yes □ No
Elections Held □ Yes □ No
How often_________________________________________________________________
Grant Program.Grant Final Report Form.1.5.2.3
Page 2
Business Meetings Held □ Yes □ No
How often_________________________________________________________________
Membership □ Yes □ No
Dues □ Yes □ No
Membership Levels
Volunteers □ Yes □ No
Approximate hours/year volunteer contribution _______________________________________
Collecting Institution □ Yes □ No Approximate % relating to Arizona history_________
Objects □ Yes □ No
Archives □ Yes □ No
Photographs □ Yes □ No
Other __________________________________________________________________________
Public Programs □ Yes □ No
Type ___________________________________________________________________________
Educational Programs □ Yes □ No
Encourage Research □ Yes □ No
Exhibits □ Yes □ No
Approximate sq. ft. of exhibit space _________________________________________________
Open to public a minimum of 208 Hours/Year □ Yes □ No
Regularly scheduled hours
Sunday _________________________________________________________________
Grant Program.Grant Final Report Form.1.5.2.3
Page 3
Monday __________________________________________________________________
Tuesday __________________________________________________________________
Wednesday ________________________________________________________________
Thursday _________________________________________________________________
Friday ____________________________________________________________________
Saturday __________________________________________________________________
Regularly scheduled closings (holidays, etc.)
________________________________________________________________________________
Significant changes from previous year □ Yes □ No If so, please explain:
I hereby affirm that the above information is correct.
Name President or Director (print) __________________________________________________
Signature of President or Director __________________________________________________
Date ______________________________
Return completed form to:
Arizona Historical Society
Certified Museum Program
1300 N. College Ave.
Tempe, AZ 85281
ahsadmin@azhs.gov
Phone: 480.387.5365
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New Renewal Arizona Historical Society Certified Museum Program

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Completed 12 August 2020

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