SIO Geological Collections Sample Request Form
Please review the SIO Geological Collections Loan Policy Statement
* Required
Requester Information #1
Name #1
*
Institution/Organization/School #1
*
Email Address #1
Phone Number #1
Fax Number #1
Requester Information #2
Name #2
Institution/Organization/School #2
Email Address #2
Phone Number #2
Fax Number #2
Requester Information #3
Name #3
Institution/Organization/School #3
Email Address #3
Phone Number #3
Fax Number #3
Shipping Address
Ship Samples to
*
Purpose (Scientific Research)
I (we) am/are requesting samples for scientific research, the results of which I (we) expect to publish in a recognized scientific journal:
*
YES
NO
If YES, please summarize your proposed research, indicate type of study, how study of samples will address scientific questions, methods and tools to be used, type of data produced, and expected publication date:
How is the research to be funded (e.g. NSF grant)?
Expected date of research completion:
MM/DD/YYYY
Purpose (Educational Projects)
I am requesting samples for classroom teaching, outreach projects, museum-type displays, conduction of public tours, or talks and other related educational projects:
*
YES
NO
If YES, please indicate nature of project, age or grade level, number of students in class, focus of study or presentation, how materials will be used and expected results as applicable:
Materials Requested
List materials requested (include expedition, core or dredge number, interval (cm) from top of core, or other descriptive information):
*
(Refer to Core and Dredge Data Index for additional information.)
Number of core samples requested:
Number of dredge samples requested:
Number of "Special Collections" samples requested:
Special Instructions/Comments:
Loan Policy Statement and Terms
I (We) have read the SIO Geological Collections Sample Loan Policy Statement and agree to its Terms:
*
YES