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Fill and Sign the Mold Remediation Completion Form

Fill and Sign the Mold Remediation Completion Form

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Museum and Community Connections 2010 APPLICATION COVER SHEET Check the category(s) under which you are applying: ___ Collaborations ___ Artist Residencies ___ Exhibits ___ Offsite Programming ___ Other SUBMITTING MUSEUM __________________________________________________ ADDRESS ___________________________________________________________________ CITY ______________________________ STATE & ZIP _____________________________ CONTACT PERSON FOR QUESTIONS ABOUT THE PROPOSAL: Name _________________________________ Title _________________________________ Phone (_____)__________ Fax (_____)____________ Email _________________________ PROJECT SUMMARY (Please do not exceed the space provided below): PROJECT STARTING DATE __________________ ENDING DATE ___________________ AGE RANGE OF POPULATION SERVED ___________ NUMBER SERVED ___________ AMOUNT REQUESTED (UP TO $75,000) $_____________ SIGNATURE OF CHIEF EXECUTIVE OFFICER OF SUBMITTING MUSEUM: SIGNATURE __________________________ DATE _____________________________ NAME ________________________________ TITLE ____________________________ PHONE ________________________________ EMAIL ____________________________ Applications must be received by Friday, October 15, 2010.

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