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* First Name:		* Last Name:
Organization Name:
Organization Type:
Museum   Arboretum/botanical garden   Aquarium   Children's/youth museum   General museum (Two or more disciplines equally)   Historic house/site   History museum   Museum association   Nature center   Natural history museum   Planetarium   Science/technology museum   Specialized museum (one defined discipline)   Zoo    Library   Academic Library   Library association   Public Library   Research library/archives   School library   Special library   State library agency    Public Broadcasting Licensee   Joint Radio and Television   Radio Only   Television Only    Other   College/university museum studies program   College/university library or information science program   Other (please specify)
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Address:
City:		State: Zip:
		AL AK AS AZ AR CA CO MP CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX VI UT VT VA WA WV WI WY
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