| Agency/Group name: ________________________________________________________________________ |
| AKA (Variant names): _______________________________________________________________________ |
| Address (Mail and/or Office): _____________________________________________________________ |
| Phone number(s): __________________________________________________________________ |
| Fax number(s): __________________________________________________________________ |
| E-mail address: __________________________________________________________________ |
| Website: _________________________________________________________________________ |
| Contact person(s) & Title(s): __________________________________________________________________ |
| Language(s) spoken by staff: __________________________________________________________________ |
| Administrative head (Director, Coordinator, etc.): ____________________________________________________ |
| Office hours (Days & Times): _______________________________________________________________ |
| Meetings (Day/Date, Time, Place): ____________________________________________________ |
| Area served: ______________________________________________________________ |
| Description: _______________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ |
| Services/Programs: ____________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________ |
| Scholarships offered (Please state amount and eligibility): ______________________________________________________________________________________________________ __________________________________________________________________________________ |
| Eligibility (for membership or services) Application? Waiting Period?: __________________________________________________________________________________________________________________________________________ |
| Fees (for membership or services) Sliding fee scale? Income eligibility?: _______________________ ______________________________________________________________________________________________________________________________________________________ |
| Do you use volunteers? If so, how?: ___________________________________________________ |
| Governing structure (Please state if you are a local chapter/office of a larger group or agency; how your funding is obtained; whether or not you are connected in some way with another agency in the area): ____________________________________________________________________________________________________ |
| Elections (Please state when new officers are elected): ____________________________________________________________________________________________________ |
| Publications (Please list name(s), where/when available): ____________________________________________ _____________________________________________________________ _____________________________________________________________ |
| Facility handicapped accessible?: __________________________________________________ |
| Facility/Meeting room (Please state if space is available for rent/public use, room capacity, fees, restrictions, and contact person): ___________________________________________________________________________________________________ |
| Additional information: ____________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ |
Please note: All information provided will be available to patrons of public libraries in the Merrimack Valley Library Consortium.
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