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
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome